Verification of Medical Expenses

Verify incurred medical expenses by one of the following:

Medical bills or statements

Receipts for payment of medical expenses

Medical Explanation of Benefits (EOB) which shows covered/non-covered and paid/unpaid medical expenses

Health insurance statements showing amount paid

Odometer readings for mileage costs

Other appropriate means

A doctor’s statement (written or verbal) indicating anticipated Medicare TPL may be used as verification until such time as the Medicare EOB is received.

If a previously “written off” bill is submitted again as owed, do not allow this bill to be used in the spenddown budget. Writing a bill off gives the provider of service a tax benefit and makes them eligible for Indigent Trust funds.

Use the following chart to determine which medical expenses can be deducted to meet the spenddown in an AMN case:

Chart 2150.1 – Allowable Medical Expenses for AMN ALLOWABLE NOT ALLOWABLE Medical bills belonging to individuals who are or could have been included in the BG when the expenses were incurred. Unpaid bills that the A/R or deemor remains liable for paying. If there is a deductible or co-payment amount to be paid by the A/R, this can be allowed. However, if a decision is pending as to who is liable, do not allow the deduction until the decision on liability is made. If a bill is paid in full or in part to a provider or as a reimbursement to the A/R or deemor by a public program funded by the state or programs of political subdivisions of the state, allow this as a deduction in the month incurred or paid, as long as no federal funds are used. Verify the source of the funding to ensure that there are no federal funds. Allow a reimbursement for this third party only if the bill was paid by the A/R and reimbursed in the same month. Do not allow the bill as a deduction if the A/R paid the incurred expenses prior to the current month and was reimbursed in the current month. Unpaid bills incurred prior to the month which were not used to meet a spenddown for another month. Bills incurred during the month, whether paid or unpaid. Bills applied to an earlier spenddown that was never met if the bills are still owed and the individual who incurred them is still a deemor or A/R’s minor child. Medical bills used in ARM AMN budgets in the spenddown process. Bills not presented to the worker during the month provided the A/R or deemor remains liable for payment as of the first day of the next month under consideration. The remainder of unpaid bills incurred prior to the month that have been turned over to a collection agency. If these medical bills are consolidated with other bills, only the portion that can be verified as unpaid medical expenses can be deducted. Monthly payments to a collection agency cannot be deducted. Medical expenses related to pregnancy, including prepayment of delivery fees or admission fees by the hospital when billed. Medical bills past or present which are/were subject to payment by a third-party liability (TPL), including Medicare. Exception: See Step 9 regarding legal issues. VA Aid and Attendance is not a TPL. Medical bills incurred in a month in which the A/R was Medicaid eligible that were not submitted to DMA or not submitted timely for payment, or which were submitted and rejected for errors in filing the claim. For ongoing AMN, past medical debts which were forgiven or written off by the provider prior to the first day of the month or prior to the date the case is brought to final disposition. Medical expenses paid by Medicaid under three months prior coverage. Medical bills applied in another month in which spenddown is met. Long term care medical bills incurred by A/R who is not found eligible for Medicaid under an LA-D COA due to a transfer penalty, may not use those bills as an expense for AMN. Emergency Medical Assistance COA: Bills from any time period can be used as long as the A/R or deemor still has a legal obligation to pay the bill. The incurred bills are not limited to the time of the emergency service. Medical bills that have been paid with the proceeds of a loan if the loan has not been fully repaid. If other expenses were also paid by the loan, consider any and all payments made on the loan to be for the medical bills. Medicare premiums for an A/R who is a self-payer are deductible the first day of each month, even if A/R is eligible as of the first day of the month using bills from previous months. Medical bills that may potentially be paid as the result of a pending lawsuit/legal issue are allowable in the month the bill is incurred. However, complete and send a Form DMA 285 regarding the pending lawsuit. A prescription drug that is NOT covered on an A/R’s Medicare Part D if the A/R provides verification that s/he has received an unfavorable decision from the carrier that it will not be covered. Medicare Part D premiums and co-pays until such time as they are picked up by Medicaid. This should occur annually within two months after the first month of AMN approval. Any prescription that is covered under Medicare Part D (excluding co-pay). Once the A/R has met SD, do not allow any prescription payments or co-pays from that point to the end of the month. These should be covered by Medicaid.