Introduction to the Community Care Program and Spenddown
The Illinois Department on Aging (DoA) Community Care Program (CCP) plays a vital role in supporting older adults by providing access to essential home and community-based services. A significant update, effective September 1, 2010, has made it easier for individuals enrolled in or applying for the CCP to manage their medical expenses in relation to Medicaid spenddown requirements. This change recognizes the costs associated with DoA/CCP services as allowable medical expenses when calculating spenddown, potentially streamlining access to crucial medical assistance for those receiving community care. This article will explain this policy update and its implications for individuals and families utilizing the Department Of Aging Community Care Program in Illinois.
Key Updates Regarding DoA/CCP Services and Spenddown
Several key changes were implemented to integrate DoA/CCP service costs into the medical spenddown process:
- Allowable Medical Expense: Costs for services received through the Department on Aging Community Care Program are now considered valid medical expenses for meeting Medicaid spenddown requirements. This means that these costs can be used to reduce the amount an individual needs to “spend down” to become eligible for Medicaid.
- System Automation for Spenddown Management: The Illinois Department of Healthcare and Family Services (HFS) implemented a system to automatically identify individuals whose DoA/CCP service costs meet or exceed their monthly spenddown amount. This system centrally manages these cases, placing them in “met status” for spenddown, simplifying the process for both clients and caseworkers.
- Retroactive Eligibility: The system can also retroactively grant Medicaid eligibility for up to three months prior to the application date if the individual was already receiving DoA/CCP services during those months and the service costs were sufficient to meet the spenddown requirement during that period.
- Pay-in Spenddown Option: Individuals receiving DoA/CCP services are also eligible to enroll in the Pay-in Spenddown program, providing another avenue to manage their spenddown obligations.
- Revised and New Notification Forms: The implementation included revisions to existing forms and the introduction of new forms to ensure clear communication about these changes. Form HFS 2538B, Illinois Department on Aging (IDoA) Notification, was revised, and a new form, HFS 2538C, Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown, was introduced.
Application Process and Medical Benefit Requirements
For individuals seeking to access the benefits of the Community Care Program, applying for medical benefits is a mandatory step. Care Coordination Units (CCUs) are responsible for guiding applicants through this process, providing assistance in completing the necessary applications.
When an individual applies for DoA services, the CCU will send Form HFS 2378H, Mail In Application for Medical Benefits, along with Form HFS 2538B, IDoA Notification, to the Family Community Resource Center (FCRC). Applicants are required to cooperate with the process by providing any necessary documentation to determine their eligibility for medical benefits, ensuring a smooth and efficient application experience.
Utilizing DoA/CCP Service Costs to Meet Spenddown Obligations
The core of this policy update is the ability to use the costs of DoA/CCP services to satisfy medical spenddown requirements. This is a significant benefit for individuals who rely on these community-based services.
It is important to note that in cases where eligibility is determined using a one-person standard (often involving spousal situations), DoA/CCP service costs incurred by one spouse cannot be applied to the spenddown obligation of the other spouse. In situations where one spouse begins receiving DoA services and separate spenddown cases are necessary, specific guidelines, detailed in PM 15-06-02-d, should be followed to ensure proper handling of spenddown calculations.
How FCRCs Utilize DoA/CCP Expenses
Family Community Resource Centers (FCRCs) play a crucial role in applying DoA/CCP expenses to spenddown calculations. When determining spenddown status, FCRCs are instructed to consider the estimated cost of DoA/CCP services as incurred on the first day of the month, regardless of when the services are actually delivered. These service costs are prioritized and applied to the spenddown requirement before considering any other medical bills or receipts the individual may have.
If the DoA/CCP service costs are not sufficient to meet the spenddown for the month in which they are incurred, these costs can be carried forward and used to meet spenddown obligations in subsequent months. There is no time limit on how long these costs can be carried forward. However, once a portion of the DoA/CCP service costs for a given month has been used to meet spenddown, any remaining amount from that month cannot be carried over further.
To verify the costs of DoA/CCP services when spenddown is not being met centrally, the CCU will provide Form 2538B. FCRCs will use the verified amount on this form to calculate spenddown, starting from the first month of DoA service approval, and will continue to use this amount until they are notified of any changes in service costs. When entering DoA/CCP service costs into the Automated Support Data System (ASDS), caseworkers should use expense Type ‘A’ to correctly categorize these expenses.
Central System Management of Spenddown with DoA/CCP Services
To streamline the spenddown process, the HFS computer system is designed to automatically identify clients whose monthly DoA/CCP service costs are equal to or greater than their monthly spenddown amount. This automated system takes over to place the case in a “met status,” removing the need for manual intervention in many cases. This automated matching process occurs monthly at schedule 08 cut-off.
To monitor and verify system actions, several reports are generated:
- Mobius Report #R8450469-03: This daily report identifies cases that have received either a Notice of Determination of Spenddown Met (Form 458SP-2) or a Notice of End of Eligibility for Medical Assistance (Form 3358A). This report serves as verification that these central notices were generated and sent when a case’s spenddown status changed due to DoA/CCP services.
- Mobius Report #R83003741: This monthly report identifies cases where services have been terminated or where the monthly cost of services is no longer sufficient to meet the spenddown through the central system.
System Actions When DoA Services Meet Spenddown:
When the system determines that DoA services are sufficient to meet spenddown, it automatically makes several updates to the case record:
- Item 80 code 390 (met/unmet indicator) is changed to ‘4’.
- Item 80 code 396 is deleted.
- The amount following Item 80 code 392 is reduced to zero if necessary.
- Item 20 code ’16’ is changed to ’18’ (unless Item 20 is already coded ’20’, in which case it remains unchanged).
- Transaction Authorization (TA) 31/Transaction Authorization Request (TAR) A4 is generated.
- Form 458SP-2 (Notice of Determination of Spenddown Met) is sent to the client.
System Actions When DoA Services are Terminated or Costs are Insufficient:
Conversely, when DoA services are terminated or the costs no longer meet the spenddown requirement, the system takes the following actions:
- Item 80 code 390 (met/unmet indicator) is changed to ‘2’.
- Form 3358A (Notice of End of Eligibility for Medical Assistance) is sent to the customer.
- Item 20 code ’18’ is changed back to ’16’.
- TA 31/TAR A5 is generated.
In situations where DoA/CCP monthly service costs are not enough to meet spenddown through the central system, caseworkers can manually apply these costs toward spenddown using the ASDS system, ensuring that all allowable expenses are considered.
Medical Backdating and DoA/CCP Services
The policy also allows for medical eligibility to be backdated for up to three months prior to September 1, 2010, if DoA/CCP service costs are being used to meet spenddown. If an individual was receiving DoA/CCP services and the monthly cost was sufficient to meet their spenddown amount during those prior months, the system will centrally backdate eligibility.
In cases where medical backdating is not done centrally, FCRCs can manually apply DoA/CCP service costs to backdate medical eligibility, provided that the CCU supplies Form HFS 2538B to verify the service costs. This ensures that individuals can receive the full benefits of Medicaid coverage, even retroactively, when eligible through DoA/CCP service costs.
Pay-in Spenddown Option for DoA/CCP Service Recipients
Individuals who are receiving DoA/CCP services have the option to enroll in the Pay-in Spenddown program. This provides an alternative method for meeting spenddown requirements. To obtain a Pay-In Spenddown Enrollment Form (Form HFS 458SP-4), individuals can contact the Healthcare and Family Services (HFS) Hotline at 1-800-226-0768 (TTY: 1-877-204-1012) and request assistance from the Pay-In Spenddown Unit. Further information on Pay-in Spenddown can be found in PM 15-08-15.
New Transaction Authorization Request (TAR) Codes
Two new TAR codes were introduced as part of this policy update, specifically for central system use related to DoA/CCP and spenddown:
| Code | Message |
|---|---|
| A4 | Spenddown obligation met with DHS-DRS/DDD or DoA/CCP service costs. Central Use Only |
| A5 | Spenddown obligation not met with DHS-DRS/DDD or DoA/CCP service costs. Central Use Only |
Forms Referenced in Policy Update
The policy update references several key forms that are essential for understanding and implementing these changes:
- HFS 458SP2 (Notice of Determination of Spenddown Met)
- HFS 3358A (Notice of End of Eligibility for Medical Assistance)
- HFS 2378H (Mail In Application for Medical Benefits)
- HFS 2538B (IDoA Notification)
- HFS 2538C (Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown)
This policy update represents a significant step forward in integrating community-based services with medical assistance programs, aiming to simplify access to healthcare for older adults in Illinois through the Department of Aging Community Care Program.
[signed copy on file]
Grace Hong Duffin
Acting Secretary, Department of Human Services
Julie Hamos
Director, Department of Healthcare and Family Services
