Allowable Medical Expenses
The following expenses can be used to meet the AMN spenddown:
Services provided by the following: Chiropractors Dentists Hospitals LPNs Medical Clinics Mental Health Clinics MR Group Homes (daily rate for treatment and training) Nursing Assistants Opticians Optometrists Osteopaths Oculists Personal Attendants (sitters) – obtain doctor’s statement that a personal attendant/sitter is necessary for A/R’s medical condition Physicians Psychiatrists RNs
Medical care purchases, such as the following: medical tests hearing aids eyeglasses contact lens dentures prescription drugs over-the-counter medical needs transportation costs to obtain medical services – the lesser of actual cost or maximum allowable amount. (See Appendix A-1 for maximum allowable mileage costs) prosthetic devices immunizations Guide Dog or other animal trained to assist a physically disabled person (include the cost of securing and maintaining animal)
Elective surgery
Medically necessary ambulance service
Health and/or dental insurance premium. If a fee or premium is paid by an entity other than the A/R, such as the Federal or state government, it is NOT treated as a medical expense for AMN.
A prescription drug that is NOT covered on an A/R’s Medicare Part D plan may only be allowed as a medical expense for AMN if the A/R provides verification that s/he has gone through the appeals process with their plan’s carrier and has received an unfavorable decision.
The following medical expenses may be projected (rather than used as a daily expense) as billed/paid for applying to the AMN spenddown: personal care home (with doctor’s statement - medical expense portion only, room and board expenses are not allowable) NH bill Personal sitter (with doctor’s statement only) The projected medical bills of personal care home, NH, and personal sitter will not be paid by DCH.
These lists are not all inclusive. Explore TPL coverage before applying any medical expense as a deduction from the spenddown. If the medical bill is questionable as to whether or not it is allowable, follow the procedures outlined in Section 2555-3 to submit IMEs for approval.