Page 307
Medical Services Policy Manual, Section H
H 400 Post Eligibility
Other allowable medical expenses (if not subject to payment by a third party) include without limitation: health insurance premiums, deductibles, and coinsurance; prescription drugs not in the Health Care formulary; and physician, hospital, and dental charges; etc. These are not subject to approval through the facility’s Quality Assessment and Assurance Committee. However, prior to making the purchase or paying the bill, the recipient or authorized representative must provide the eligibility worker with proof that the item or items were prescribed by a physician or other licensed medical practitioner, including proofof the cost. A copy of the health insurance bill can be used for proof of health insurance premiums, deductibles, and coinsurance. Medicare premiums deducted from SSA payments prior to buy-in are not allowed as they will be reimbursed. The only allowable medical deductions will be the recipient’s noncovered medical expenses. Medical expenses of family members cannot be deducted from facility income. NOTE: There is no monthly limit on the number of prescription drugs for facility recipients receiving vendor payment, as long as the prescribed medicine is within the Health Care formulary. Health Care facility recipients who are not certified for vendor payment are limited to three (3) prescriptions permonth. Nursing facility hospice recipients are eligible for three (3) prescriptions drugs per month, with the option of receiving up to six (6) prescriptions with prior authorization.
Medical expenses can be of three types: • Monthly - Expenses regularly incurred each month such as the Medicare Part D enhanced plan portion of premiums above the benchmark; • Nonmonthly - Expenses which are not incurred monthly but are incurred periodically, such as quarterly insurance premiums; or • One-time - Expenses incurred such as hearing aids. If the eligibility worker is unable to determine within a fair degreeof certainty whatthe non- covered medical expenses will be, then no medical expenses will be deducted from the income.