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60 TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 20620.2 Necessary Medical Care Expenses 20620.2.1 Medical Insurance Premiums 20620.2.2 Necessary Medical Care 20620.2.3 Prior Medical Costs 20620.2.1 Medical Insurance Premiums Cost of medical insurance premiums carried by the recipient shall be set aside from his/her income. A medical insurance premium which is payable less often than monthly (for example, quarterly) may be averaged out so that a consistent amount of the recipient's income is protected for this purpose each month. The recipient, or other person responsible for his financial affairs, will be responsible for handling this money and assuring that is available for paying the premium when due. 20620.2.2 Necessary Medical Care Cost of necessary medical care not covered under the recipient's medical insurance, Medicaid or Medicare but recognized under state law may be set aside from his/her income. The care must be ordered by a professional, such as a physician, dentist, optometrist, physical therapist, etc. For items such as dentures and hearing aids to be approved a medical professional will have to state, in writing that the patient will benefit medically (as opposed to cosmetically only). Other approved medical care items which might occur frequently are eye exams, eyeglasses, dental care, prostheses and appliances. When in doubt as to whether the care is recognized under state law or is appropriate to be charged to the patient under this policy, consult the Long Term Care Operation’s Administrator. The recipient and the provider must understand that these are not Medicaid payments but are an arrangement between recipient and provider, and that it is the responsibility of the recipient, or his representative to see that payments are made. If both parties are agreeable, payments may be spread out over a period of months. 10 DE Reg. 703 (10/01/06) 20620.2.3 Prior Medical Costs Medical costs incurred in a prior period of ineligibility (if approved by Medicaid) may be protected from his/her income. Costs incurred in a period of ineligibility must be approved by the Medicaid State Office prior to being protected and will only be considered if incurred within three (3) months of the beginning date of Medicaid eligibility. The recipient's reimbursement level and patient pay amount must be identified. Medicaid will protect at the Medicaid reimbursement rate, not the private pay rate. The period of ineligibility may be caused by excess resources or excess income. Protections for which the individual is seeking coverage will not be granted if the ineligible period occurred during a transfer of assets penalty phase. 10 DE Reg. 703 (10/01/06) 21 DE Reg. 435 (11/01/17) 20620.3 Community Spouse Income Allowance/Home Maintenance Disregard Temporary Institutionalization - If the attending physician has certified that a recipient is likely to return to his own home within a definite period (not to exceed 2 months) up to $75.00 per month may be protected for maintenance of the home. This allowance may be used for mortgage payments, rent, insurance, utility bills, repairs, etc. Copies of receipts, contracts or other types of verification shall be obtained and kept in the DSS record. The $75 home maintenance disregard may not be allowed if the community spouse is receiving the spousal income allowance. 9 DE Reg. 1076 (01/01/06) 20620.4 Family Allowance To determine community spouse income allowance and family allowance for recipients institutionalized after 9/30/89 see section on Spousal Impoverishment. For recipients institutionalized prior to 9/30/89, an additional amount must be protected for the maintenance needs of the recipient's needy spouse and/or dependents in accordance with TANF standards. If the family has earned and/or unearned income, work expense and dependent care costs should be deducted to determine monthly net income. Use standard TANF deductions. The monthly net income should then be deducted from allowances given above to determine the amount to be protected. Standard TANF deductions: $90 per each employed person $30 and 1/3 disregard up to $200/month/child under two up to $175/month/child age two and older and incapacitated adult