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MEDICAL SERVICES POLICY MANUAL,SECTION O O-700 Income Determination for Medically Needy Program

O 751 Medicare Coverage Types

expenses not paid by third party resources is the liability of the individual and can be deducted from excess income. Statements which are received from third party resources within a reasonable period of time can be used to determine the liability of the individual if they indicate either the amount of payment to be made or that no payment is to be made. When statements indicate the amount of payment to be made, the indicated amount of payment will be applied to the cost of incurred medical expenses to determine the liability of the individual (i.e., it will be treated as if it were an actual payment). When statements indicate that no payment is to be made, the total amount of incurred medical expenses is the liability of the individual and can be deducted from excess income. When a third party resource has not made payment, does not indicate the amount of payment to be made, or indicates that no payment is to be made within a reasonable period of time, the actual liability of the individual cannot be determined and the incurred medical expenses cannot be deducted from excess income.  NOTE: For administrative ease, the time limit imposed for the disposition of the applicable Medically Needy application (45 or 90 days) will be considered to be “a reasonable period of time” to obtain verification ofmedical expenses paid by a third party. The most common third party resources are Medicare and private health insurance. To facilitate an accurate determination of an individual’s liability, these resources should be treated as follows:

O-751 Medicare Coverage Types MS Manual 01/01/14 Medicare consists of two types of coverage: 1. Part A - Hospital Insurance - coverage is provided for inpatient hospital care, post hospital extended care and post hospital home health care and skilled nursing care. Part A pays Medicare per diem rate, less any unmet deductible(s) and/or coinsurance. Under Part A - Medicare pays direct to the hospital/supplier. The hospital/supplier agrees to accept the Medicare per diem rate. The actual liability of the individual is limited to the following, where applicable: