Section 1020. Definitions

Part VI. Deduction of Incurred Medical Expenses in Determining Countable Income (Spenddown)

"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.

Historical Notes

Derived from VR460-10-8.2600 § 1, eff. April 30, 1995.

Statutory Authority

§ 32.1-325 of the Code of Virginia.