LTC Medical Expense Deduction (Archive)

Allow 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.

Medical Expenses.

Co-Payments.

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Medical Expenses

Use 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 will not be paid 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 expense deduction. People may incur this expense when they reside in a residential living arrangement Community living arrangements such as group residential housing (GRH), board and lodge, and corporate and foster care settings that provide supportive services. where a county has a GRH agreement.

l  Do not allow unpaid medical bills incurred prior to the month of the income calculation as a deduction.

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Co-Payments

Co-payments incurred by a client 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 clients are exempt from MA co-payments if the Physician Certification form (DHS-1503) indicates the placement is expected to last 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 an LTCF, intermediate care facility for persons with mental retardation or related conditions (ICF/MR) or MA-paid psychiatric hospital is exempt from Medicare Part D co-payments. The client will be responsible for these co-payments until such time that DHS notifies the Centers 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 A Medicare Part D cost-sharing subsidy program. Full-benefit, dual eligible enrollees are automatically eligible for the full Extra Help subsidy. Others may apply to the Social Security Administration for full or partial Extra Help subsidies. 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.

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