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Effective: December 1, 2006 |
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23.40.50ar1 - LTC Medical Expense Deduction (Archive) |
Archived: December 1, 2007 |
Allow other reasonable and necessary medical expenses as a deduction in the LTC income calculation.
Note: Do not use this deduction for clients determined to have a Combination LTC/Medical Spenddown.
Use the medical expense as a deduction if all of the following conditions are met:
l The client must actually incur the expense during the certification month.
l The client must be responsible to pay the medical expense. A third party cannot be responsible for the payment.
l The expense is not covered by MA.
l The expense is recognized under state law as medically necessary. Examples of allowable expenses not covered by MA include but are not limited to:
n Necessary dental procedures.
n Electric wheelchair for a person in a nursing home.
n Remedial care.
A person may incur this expense when:
m They are private pay in a Group Residential Housing (GRH) facility.
m They are receiving residential care or assisted living services in a non-GRH setting through EW, CADI or TBI waivers.
For more information on remedial care bills, see P Bills and Remedial Care.
l Do not allow unpaid medical bills incurred prior to the month of the income calculation as a deduction.
Some co-payments a client is responsible for may be used as a medical expense in the LTC income calculation.
l Deduct a co-payment in the month the service is received.
l Do not anticipate co-payments for the current or future months. Adjust the budget when a client reports a co-payment.
l Allow an MA co-payment as a deduction if:
n The client is receiving SIS-EW.
n A client who is exempt from MA co-payments but is not reimbursed for an MA co-payment they have paid.
Note: MA client’s are exempt from MA co-payments if the Physicians Certification Form (DHS-1503) indicates the placement is for more than 30 days.
l Allow co-payments made for Medicare Part D.
n Deduct the co-payment for the month of service.
n A client enrolled in MA and residing in a LTCF, Intermediate Care Facility for people with Mental Retardation or Related Conditions (ICF-MR) and MA-paid psychiatric hospitals is exempt from Medicare Part D co-payments. The client will be responsible for these co-payments until such time that DHS notifies the Center for Medicare and Medicaid Services (CMS) of the client’s exemption. Continue to allow the deduction until the client is exempt.
n Do not allow co-payments or co-insurance paid by the Extra Help program.
m See Medicare Part D for more information on Extra Help.
m See MA/GAMC and Medicare Part D for information on how Extra Help affects a spenddown or LTC income calculation.