Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1020 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
"AFDC" means Aid to Families with Dependent
					 Children.
"Applicable disregards" means the amounts that would be
					 deducted in determining eligibility under AFDC for families and under SSI for
					 aged, blind and disabled recipients.
"Available income" means the earned and unearned income
					 used in determining the financial eligibility of a medically needy
					 individual.
"Budget period" means a prospective period of time during
					 which an individual's income is calculated to determine eligibility.
"Budget unit" means a subunit of the family unit which is
					 used in calculating countable income and resources when deeming of income and
					 resources between family members would violate the Social Security Act.
"Countable income" means, for the medically needy, the
					 amount of an applicant's income measured against the medically needy income
					 level (MNIL). Countable income is determined by deducting the following amounts
					 from reported gross income:
1. For
				  individuals under age 21 and caretaker relative, amounts that would be deducted
				  in determining eligibility under the state's AFDC plan, except for those
				  prohibited under Title XIX of the Social Security Act.
2. For aged, blind, or disabled individuals,
				  amounts that would be deducted determining eligibility under SSI and (i) any
				  SSI benefits, (ii) any auxiliary grant, and (iii) other deductions from income
				  applied under the Medicaid plan. This figure is measured against the income
				  level for Medicaid eligibility.
"Expenses covered in the plan" means expenses for services
					 included in the State Plan for Medical Assistance including those that exceed
					 agency limitations of amount, duration or scope of services.
"Expenses not covered in the plan" means expenses for
					 necessary medical and remedial services recognized under State law but not
					 covered under the State Plan for Medical Assistance.
"Excess countable income" means the amount of income to be
					 applied toward incurred medical expenses and is determined by subtracting the
					 MNIL from the countable income.
"Family unit" consists of all individuals listed on the
					 application form as living in the household and among whom legal responsibility
					 under state law exists.
"Financially responsible relative" means a spouse or parent
					 whose income is actually used in determining eligibility.
"Incurred expenses" means medical or remedial
					 services:
1. Which are recognized
				  under state law;
2. Which are
				  rendered to an individual, family, or financially responsible
				  relative;
3. For which the
				  individual is liable in the current accounting period or was liable in the
				  three-month retroactive period; and
4. Which are not subject to payment by any
				  liable third party.
An expense for medical or remedial service is an incurred
					 expense from the beginning of the accounting period in which the liability
					 arises until the end of the accounting period in which the liability is
					 satisfied.
"Institutionalized individual" means an individual residing
					 in a long-term care institution or covered under a home and community-based
					 waiver for 30 consecutive days.
"Liable third party" means any individual, entity or
					 program that is or may be liable to pay all or part of the cost of medical or
					 remedial treatment for injury, disease, or disability of an applicant or
					 recipient of Medicaid.
"Medically needy income level" or "MNIL" means the income
					 standard established to determine the eligibility of medically needy
					 individuals and families.
"Old bills" means medical or remedial care expenses
					 incurred prior to the initial application month and application's retroactive
					 period, and which were not deducted from (counted in) any previous spenddown
					 that was met.
"Projected expenses" means expenses for services that have
					 not yet been incurred but are reasonably expected to be.
"Service dates" means dates of incurred medical
					 expenses.
"Spenddown" means the process through which countable
					 income is compared to the MNIL for the budget period and incurred medical and
					 remedial care expenses are deducted from income in excess of the MNIL.
"Spenddown liability" means amounts by which countable
					 income exceeds MNIL for the budget period.
"SSI" means Supplemental Security Income.
"State or territorial public program" means a program that
					 is operated (i.e. administratively controlled) by a state or territory
					 (including a political subdivision thereof).
"State or territorially-financed program" means a state or
					 territorial public program whose funding, except for deductibles and
					 coinsurance amounts required from program beneficiaries, is either:
1. Appropriated by the state or territory
				  directly to the administering agency, or
2. Transferred from another state or
				  territorial public agency to the administering agency.