Current through Register Vol. 56, No. 18, September 16, 2024
(a) Persons who
are eligible in all respects for the Medically Needy Program, except that the
countable income of the budget unit as determined in subchapter 4 exceeds the
medically needy income level, may establish eligibility for payment of covered
services benefits through medical spend-down.
1. Medical spend-down is a process whereby
the excess countable income of a budget unit is offset by the allowable
incurred medical expenses of the budget unit.
2. Spend-down liability is the amount by
which the countable income of the budget unit exceeds the medically needy
income level as determined under the provisions of this subchapter.
(b) The retroactive eligibility
period is the three calendar months immediately preceding the month in which
application for benefits is made. For each of the three months, a monthly
spend-down liability is established. The monthly spend-down liability shall be
the amount by which actual countable income of the budget unit for that month
exceeds the medically needy income level for that month.
1. Within the retroactive eligibility period,
income eligibility is established for any month in which the allowable incurred
medical expenses of the budget unit exceed the spend-down liability established
for that month.
2. Eligibility for
payment of covered services is established effective with the first day of each
or any month in which the allowable incurred medical expenses of the budget
unit exceed the spend-down liability only for those claims for services that
are not covered under the Medically Needy Program and were not used to meet
spend-down liability. (Note: The effective date to be entered in the Medicaid
Status File is the day after the day that spend-down liability is
met.)
(c) Except for
retroactive eligibility, income eligibility for the Medically Needy Program is
determined using a six-month prospective eligibility period. The six-month
period begins with the month in which application for benefits is made. For the
full six-month period, a six-month spend-down liability is established. The
six-month spend-down liability shall be the amount by which the countable
income of the budget unit, as determined at N.J.A.C. 10:70-4, exceeds the
budget unit's medically needy income level for the full six-month period.
1. Eligibility for medically needy benefits
is established effective with the first day of the month in which the allowable
incurred medical expenses of the budget unit exceed the six-month spend-down
liability only for those claims for services that are covered under the
Medically Needy Program and were not used to meet spend-down liability. (Note:
The effective date to be entered on the Medicaid Status File is the day after
the day spend-down liability is met.)
2. Changes in the countable income of the
budget unit and/or the size of the budget unit during the six-month prospective
period require a recalculation of the six-month spend-down liability.
3. In order to receive program benefits, upon
meeting the spend-down liability, all other factors of program eligibility must
also be met.
