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Effective: December 1, 2006 |
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24.15.25ar1 - P Bills (Archive) |
Archived: January 1, 2010 |
"P" bills are one type of health care expense which have dates of service during the certification period and are generally non-reimbursable by MA, GAMC or MinnesotaCare (MCRE).
P bills are applied to the spenddown after H bills and M bills are applied. Once P bills are applied to the spenddown see R bills.
For information which affects all health care expenses see Health Care Expenses.
Non-Reimbursable Health Care Expenses.
Dependent and Relative Expenses.
State-Funded MinnesotaCare Fee-For-Service Bills.
The following health care expenses, if incurred during the certification period for which eligibility is being determined, are considered P bills:
l Non-reimbursable health care expenses, which include MA and GAMC co-payments.
l Non-reimbursed Health Care Access Services.
l Dependents or financially responsible relative health care expenses.
l The remedial care expense deduction may be used if the client is living in any of the following:
n Regional treatment center (RTC).
n Group Residential Housing (GRH).
n Assisted living.
l Alternative Care costs.
Alternative Care is a state-funded program. Apply the client's out-of-pocket expense and the state-funded payments. Contact the case manager for amounts incurred and dates of service.
l Minnesota Children Special Health Needs (MCSHN) expenses paid by the program.
This is a program administered by the Minnesota Department of Health. Apply the client's out-of-pocket expense and the state-funded payments. Contact the case manager for amounts incurred and dates of service.
l Expenses paid by the Insurance Extension Program which pays health insurance premiums for individuals who are HIV positive.
The amount of the state-funded payment may be used as a health care expense. Contact the caseworker at DHS for the amounts of the state-funded payments and dates of service if the client has an HH span on RELG.
l State-Funded MinnesotaCare fee-for-service bills.
For information on when to apply P bills to the spenddown see the following sections:
l Automated Monthly Spenddown.
Non-Reimbursable Health Care Expenses
Non-reimbursable health care expenses are expenses that are not covered by MA, GAMC, or MinnesotaCare.
l For ongoing non-reimbursable expenses, verify the need for the item at each renewal unless the physician's recommendation specifies a shorter period.
l To qualify as an allowable spenddown expense for MA, the non-reimbursable health care service must meet all the following conditions:
n Prescribed or recommended in writing by the client's physician or dentist.
n Directly benefits the client.
n Available through a licensed medical provider but not necessarily obtained through a licensed medical provider.
Example:
Jim's dentist, a licensed provider, refers him to a specialist who is not a licensed provider.
Action:
Although the expense is not reimbursable through MA, allow it as a non-reimbursable health care expense applied to Jim’s spenddown.
Example:
Glenda purchased vitamins through a mail-order company. Her physician advised her to take the vitamins for 12 months.
Action:
Although the mail order company is not a licensed provider and cannot be reimbursed, the vitamins could have been obtained through a licensed pharmacy. Allow the expense as a non-reimbursable health care expense applied to Glenda’s spenddown.
n Not reimbursable through the county health care access plan.
n Medically necessary.
A medically necessary service is a health service rendered for any of these situations:
m In response to a life-threatening condition or pain.
m To treat an injury, illness, or infection.
m To achieve a level of physical or mental function consistent with prevailing community standards for the diagnosis or condition.
m To care for a mother and child through the maternity period.
m To provide preventive health service.
m To treat a condition that could result in physical or mental disability.
m The provider's professional peer group must recognize the service as the prevailing standard or current practice and as consistent with the client's diagnosis or condition.
Clients should report and verify co-payments for which they are responsible.
l Do not anticipate MinnesotaCare, MA, and GAMC co-payments.
l Allow co-payments as health care expenses in the month of the date of service. Enter actual dates of service for each co-payment.
Exception: Do not allow co-payments or co-insurance paid by the Extra Help program.
l See Medicare Part D for more information on Extra Help.
l See MA/GAMC and Medicare Part D for information on how Extra Help affects a spenddown or LTC income calculation.
l Once the client reports and verifies the co-payment, recalculate the spenddown.
Note: After spenddown recalculation, DHS will send the adjustments to providers. The reimbursements will not always go to the providers who collected the co-payments. It will go to the first provider who had a spenddown-reduced claim for that month's services. The client should receive a refund or credit from the provider who received the reimbursement. Allow two to four weeks for providers to receive the adjustments.
n Six-Month and Manual Monthly Spenddowns.
m If the spenddown recalculation results in a lower recipient amount on the original satisfaction date, DHS will reprocess claims automatically. The provider should not rebill.
m If the spenddown recalculation results in an earlier satisfaction date, DHS will reprocess claims automatically from the original satisfaction date forward. The client should notify providers to bill claims from the new satisfaction date through the day before the original satisfaction date.
n Automated Monthly Spenddowns.
The spenddown recalculation will decrease the client's spenddown amount. DHS will reprocess claims automatically. Providers should not rebill for automated month spenddown adjustments.
Allow the following for these programs:
l MinnesotaCare co-payments.
Allow the MinnesotaCare co-payments as health care expenses for other household members who are eligible for MA with a spenddown. See MinnesotaCare Expenses.
l MA co-payments.
Allow the MA co-payments as health care expenses. Enter the actual dates of service.
l GAMC co-payments.
Allow GAMC co-payments as health care expenses for other household members who are eligible for MA with a spenddown. Enter the actual dates of service.
Reimbursable expenses under the Health Care Access Services, such as transportation costs, which were not reimbursed or paid as access services can be used as a health care expense if both of these conditions:
l The managed care health plan coverage does not cover them.
l The county will not be reimbursing the expense through the Health Care Access fund.
If other health care expenses are equal to or more than the client's spenddown amount, consider which choice is more advantageous, allowing the client to choose:
l Apply the access bills to satisfy the spenddown. (This will decrease the client's spenddown amount on MMIS.)
l Receive reimbursement through the county health care access services plan.
Note: If only part of the access bills will satisfy the spenddown, the county may reimburse the balance to the client from the access fund.
Health care expenses incurred by dependents or financially responsible relatives who are not applying or eligible for MA/GAMC may be used to meet another household member’s spenddown. Include the following health care expenses:
l Reimbursable expenses which can be paid through MMIS.
l Non-reimbursable expenses which are not covered by MA/GAMC or cannot be paid through MMIS such as co-payments.
l Bills paid by MinnesotaCare for family members for whom DHS does not receive FFP. See MinnesotaCare Expenses for instructions on which MinnesotaCare expenses are allowable.
Note: Household member expenses incurred before the certification period are M bills.
State-Funded MinnesotaCare Fee-For-Service Bills
Allow the amount of fee-for-service bills paid by the state for MinnesotaCare eligible household members. These MCRE clients are not on a managed care plan.
l Verify the amounts and dates of service with an Explanations of Medical Benefits (EOMB) or other statements.
l For more information see MinnesotaCare Expenses.
l When MinnesotaCare clients apply for overlapping MA to cover inpatient hospital bills, see R Bills.
l The following MinnesotaCare Major Programs receive state funding:
n BB: Non-pregnant adults without children, regardless of citizenship.
n JJ: Legal guardians, and foster parents and noncitizen parents and relative caretakers who do not qualify for federally-funded health care coverage.
n KK: Non-citizen children and pregnant women who do not qualify for federally-funded health care coverage. For more information see Citizenship and Immigration Status.
Outstanding bills for services received from an out-of-network provider may be P bills for a managed care client. The reason the client went to an outside provider does not matter. Whether the service is a Minnesota Health Care Programs (MHCP) covered service is not relevant.
If a managed care client received services from a provider who is not in the health plan's network, the health plan may deny coverage.
l If the services are the household's financial responsibility, the services are allowable spenddown expenses.
l The bill must meet these conditions:
n The date of service is during the certification period for which eligibility is being determined.
n 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.
n The health plan formally denied the claim because the provider is not in the health plan's provider network.
n Verify the denial either with an Explanation of Medical Benefits from the health plan or another document.
n The client is financially responsible for the expense.