Wis. ForwardHealth Online Handbook, Hospice, Topic #281

Occasionally, an individual with significant medical bills meets all enrollment requirements except those pertaining to income. These

individuals are required to "spenddown" their income to meet financial enrollment requirements.

The certifying agency calculates the individual's spenddown (or deductible) amount, tracks all medical costs the individual incurs,

and determines when the medical costs have satisfied the spenddown amount. (A payment for a medical service does not have to

be made by the individual to be counted toward satisfying the spenddown amount.)

When the individual meets the spenddown amount, the certifying agency notifies ForwardHealth and the provider of the last

service that the individual is eligible beginning on the date that the spenddown amount was satisfied.

If the individual's last medical bill is greater than the amount needed to satisfy the spenddown amount, the certifying agency notifies

the affected provider by indicating the following:

• The individual is eligible for benefits as of the DOS (date of service) on the last bill.

• A claim for the service(s) on the last bill should be submitted to ForwardHealth. (The claim should indicate the full cost of

the service.)

• The portion of the last bill that the individual must pay to the provider.

The certifying agency also informs ForwardHealth of the individual's enrollment and identifies the following:

• The DOS of the final charges counted toward satisfying the spenddown amount

• The provider number of the provider of the last service

• The spenddown amount remaining to be satisfied

When the provider submits the claim, the spenddown amount will automatically be deducted from the provider's reimbursement

for the claim. The spenddown amount is indicated in the Member's Share element on the Medicaid Remaining Deductible Update

(F-10109 (02/2014)) form sent to providers by the member's certifying agency. The provider's reimbursement is then reduced by

the amount of the member's obligation.