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Effective: December 1, 2006 |
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24.15.20ar1 - M Bills (Archive) |
Archived: January 1, 2010 |
”M" bills are one type of health care expense which are unpaid medical expenses incurred prior to the certification period. These are old bills the client is still obligated to pay.
H bills are applied to a spenddown first, followed by M bills and P bills.
For information which affects all types of health care expenses, see Health Care Expenses.
Loans and Collection Agencies.
M bills must have been incurred prior to the certification period for which eligibility is being determined.
l The expense cannot have been either:
n Used to calculate a spenddown during a prior certification period, whether or not the calculation resulted in the spenddown being met. See Determining Net Health Care Expenses for information on what portion of an M bill may be used.
Exception: The expense may be used to meet another spenddown if eligibility for the entire certification period was denied.
n An MA/GAMC covered service incurred in a prior certification period of MA/GAMC eligibility.
l The health care expense may be:
n An expense charged directly to the person by a medical provider.
n An expense which a medical provider has transferred for collection to a person or agency actively pursuing the collection.
n A loan payment owed to a person, financial institution, or credit company for which the loan proceeds were specifically paid to a medical provider.
l Clients remain responsible for paying expenses used to meet their spenddown.
For information on when to apply M bills to the spenddown, see the following sections:
l Automated Monthly Spenddown.
Outstanding bills for services received from an out-of-network provider may be M bills for a managed care client. The reason the client went to an outside provider does not matter. Whether the service is an MHCP covered service is not relevant.
The bill must meet all of these conditions:
l The date of service is before the current certification period.
l The provider billed the health plan.
Note: The provider should bill the health plan even if the provider is not in the plan. Health plans have provisions for covering out-of-network services.
l The health plan formally denied the claim because the provider is not in the health plan's provider network.
Verify the denial either with an Explanation of Medical Benefits from the health plan or another document.
l The client is financially responsible for the expense.
The client may be making payments on a loan that was taken out specifically for payment of health care expenses.
l The lender can be any of the following:
n Person.
n Financial institution.
n Collection agency.
n Credit company.
Note: The client may have set up a credit card account only for payment of specific health care expenses.
l Allow the expense as M bills if the loan meets all of these conditions:
n The loan proceeds were paid specifically to a medical provider.
n The bills are in active collection. If the provider or collection agency wrote off the bills or if the bills are not in active collection, do not include them.
n The bills must be the responsibility of the client, or dependents of the client, or other financially responsible relatives who are not requesting MA.
n The bills are verified including the purpose of the loan and the balance owed.
l Use only the medical expense portion calculation. Do not apply these amounts to the spenddown:
n Accumulated interest.
n Late fees.
n Other related charges.