Verification of Medical Expenses

Explore TPL coverage before applying any medical expenses as deductions from the SD.

Verify incurred medical expenses by any one of the following:

itemized medical bill or statement

receipts for payment of medical expenses

medical Explanation of Benefits (EOB) listing covered/ non-covered and paid/unpaid medical expenses

health insurance statement listing amount paid

odometer reading for mileage expense

other sources deemed appropriate.

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

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

Chart 2196.1 – Allowable Medical Expenses for FM-MN 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 a BG member remains liable for paying. Unpaid bills incurred prior to the budget period and not used in a prior month(s) determination of eligibility nor used to meet a prior spenddown. Bills that a BG member incurred during the budget period, whether paid or unpaid. Bills applied to an earlier spenddown that was never met can be deducted in a current spenddown if the bills are still owed and the individual who incurred them is still a BG member. Medical bills NOT used in Aged, Blind, Disabled MN budgets in the spenddown process. Bills not presented to the worker during the budget period provided the BG member remains liable for payment as of the first day of the new budget period. For prior months MN budget period only: past medical debts, which have been written off subsequent to the budget period. If the bill was forgiven or written off prior to the end of the budget period, it is not allowed. the remainder of unpaid bills incurred prior to the budget period that has 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: allow when BG becomes obligated for payment of the expense include prepayment of delivery fees or admission fees by the hospital. Bills from any time period can be used as long as a BG member still has a legal obligation to pay the bill. The incurred bills are not limited to the time of the emergency service. Medical bills past or present, which will be paid by a liable third party. EXCEPTIONS: Deductibles and co-pays to be paid by the BG are allowed. If a decision is pending as to who is liable, allow the deduction with the understanding that the eligibility is revoked if the decision is reversed. If a bill is paid in full or in part to a provider, or as a reimbursement to a BG member by a public program funded by the state or programs or political subdivisions of the state, allow this as a deduction as long as no federal funds are used and the bill was paid during the budget period. Verify the source of the funding to ensure there are no federal funds used. Allow a reimbursement for this third party only if the bill was paid by the BG member and reimbursed in the same budget period. Do not allow the bill as a deduction if the BG member paid the incurred expenses prior to the budget period and was reimbursed in the budget period. For ongoing MN budget periods, past medical debts, which were forgiven or written off by the provider prior to the first day of a budget period, 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 budget period in which spenddown is met.

Use the following chart to determine procedures for the use of Form 400 and 962 in MN.

Chart 2196.2 – MN Instructions on Forms 400 and 962 IF THEN ISSUE ACTION / REQUEST / CERTIFICATION FORM 962 THEN ISSUE DMA FORM 400 THEN ISSUE MEMBER NOTIFICATION There was spenddown at the time of application but it was met with bills incurred prior to the budget period. To member for providers if unable to enter in system. Fax form 962 to HP to manually update on GAMMIS. Put an “N” for no on the form DMA400 being required in the Medically Needy Information section. Retain a copy for the case record. Not required. No first day liability is put on the form if system notice not used. Spenddown is met by a BG member who is potentially Medicaid eligible and the bill is issued by a Medicaid provider for a Medicaid-covered expense. Also, spenddown is met with bills incurred during the budget period. To member for providers if unable to enter in system. Fax form 962 to HP to be manually updated on GAMMIS. Note in the Medically Needy Information section regarding the DMA400 being required. Retain a copy for the case record. To provider, whose bill meets spenddown (i.e., the break-even claim). Show the actual dollar amount to be paid by the member for that bill. To every Medicaid provider with a subsequent bill on the BAD, show the amount to be paid by the member as zero. In both of the above situations, keep a copy of each form DMA 400 in the case record. If system notice not used, enter the first day liability amount (column 5, Form 238 on the line immediately preceding the first line of the BAD). Spenddown is met with bills incurred by a BG member who is not Medicaid eligible or with a bill from a non-Medicaid provider or with an expense that is not covered by Medicaid. To A/R for providers if unable to enter in system. Put an “N” for no on the form DMA400 being required in the Medically Needy Information section. Retain a copy for the case record. Not required. No first day liability is put on the form if system notice not used.