ZE MedNeedy by nw17D34


									         The Medically Needy Program

The Medically Needy program provides medical coverage to people who have
high medical expenses but too much income or resources to qualify for regular

Categories of Medicaid coverage include:
    Pregnant women
    People under age 21
    Adults who care for dependent children under age 18 (19 if still in school)
    People who are age 65 or older, legally blind, or disabled

Participants of the Medically Needy program are eligible for payment of all
services covered by Medicaid except:
    Care in a nursing facility, including a Medicare-certified nursing facility or
       NFMI, or ICF/MR
    Care in an institution for mental disease


If a Medically Needy member's income exceeds income guidelines, the individual
will be required to "spenddown" some of their income by paying for a portion of
outstanding medical expenses before receiving a Medicaid card. A spenddown
is similar to a deductible for each certification period.

The amount of spenddown is determined by the DHS Income Maintenance
Worker. A certification period for a Medically Needy participant is two months at
length. At the end of two months, a member with a spenddown must file a new

Verifying Eligibility

With the change to Medical Assistance Cards, members on Spenddown may
have a card but may not be eligible for any certain month. Providers must verify
eligibility for each service through either ELVS or the Web Portal. The member
may provide a Medically Needy Notice of Decision letter outlining their eligibility,
or their State Identification Number. A Medically Needy participant is responsible
for payment of services used to meet spenddown.

Iowa Medicaid Enterprise                                                        2009
Submitting Claims

Claims to be considered for spenddown are sent to either the Income
Maintenance Worker or the IME, depending on eligibility or medical service.

      Income Maintenance Worker

             The below expenses will be applied towards spenddown balance
              but will not be payable by Medicaid. The DHS income Maintenance
              Worker will attach the necessary documentation to the claim and
              forward it to the IME for spenddown processing.

             Medical expenses incurred when the client did not have a medically
              needy certification period.

             If you are billing for services that were incurred before the
              member’s Medically Needy certification period and that were
              unpaid on the first day of that certification, these services can only
              be counted towards the spenddown by submitting the claims to the
              Income Maintenance Worker. These services cannot be paid once
              spenddown is met.

             Medical expenses incurred for non-covered Medicaid services
              (nursing facility, transportation, etc.).

      IME

             Unless one of the above situations applies, you will always submit
              your spenddown claim (paper or electronically) to the IME as you
              would any other Medicaid claim. If the Medically Needy member
              has not met spenddown, the claim will be applied toward the
              spenddown balance and will not be payable by Medicaid.

Claims that are not used to meet spenddown or that are only partially used
will automatically be resubmitted for payment. The provider will not need to
resubmit these claims.

Iowa Medicaid Enterprise                                                       2009

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