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Medical Services Policy Manual, Section H
H 400 Post Eligibility
7. Non-covered Medical Expenses Non-covered medical expenses of all facility recipientsthat are not subject to payment by a third party will be deducted. Per 42 CFR § 435.725, this includes incurred expenses for medical or remedial care that are not subject to payment by a third party, including — • Medicare and other health insurance premiums, deductibles, or coinsurance charges and • Necessary medical or remedial care recognized under state law but not covered under the state’s Health Care plan, subject to reasonable limits the agency may establish on amounts of these expenses Reasonable limits on amounts for necessary medical or remedial care not coveredunder Health Care: • The non-covered expensesmust be incurred no earlier than the three-month period preceding the month of application. • The non-covered expensesmust be prescribed by a Medical professional (for example, a physician, dentist, optometrist, chiropractor, etc.). • Payments for cosmetic or elective procedures (for example, face lifts or liposuction) will not be allowed except when prescribed by a medical professional. • The expense amount is the least of the fee recognized by Health Care, Medicare, or the average cost allowed by a commercial health insurance plan in Arkansas. • Expenses incurred as a result of the imposition of a transfer of assets penalty are not allowed. • Expenses resulting from the failure to obtain prior approval from applicable private insurance, Medicare, or Health Care, due to the service being medically unnecessary, are not allowed. • Deduction is not allowed for procedures allowed by Health Care when prior authorization is denied due to the service being medically unnecessary. • Expenseswhen a third party (including Health Care) is liable for the expenses, even if provided by an out-of-network provider, are not allowed. • General health insurance premiums paid by someone other than the recipient (excluding the community spouse) who is not a financially responsible relative and repayment is not expected to be paid back to the third party by the recipient, are not allowed.