Allowable Medical Expenses

Medical expenses are used to meet the SD if they meet all of the following conditions:

the bill is unpaid Medical bills paid during the budget period are allowed.

a BG member is legally obligated to pay the expense

there is no TPL coverage to pay the expense. Refer to Special Considerations and Chart 2196.1 – Allowable Medical Expenses for FM-MN in this section.

The SD may be met using medical expenses incurred prior to the budget period. If this situation occurs, the AU is eligible from the first day of the one-month budget period. Any remaining portion of the unpaid expense not used to meet SD in a month may be used to meet SD in subsequent months, provided the bill remains unpaid during those months.

If the SD is not met by previously incurred bills, the case is held in suspense status until bills are incurred that meet the SD for any month in the renewal period.

SD that remains in suspense status should be closed with the correct closure codes to refer to the Federally Facilitated Marketplace (FFM).

If the SD is met during a budget period, a first day liability (FDL) is calculated for the day the SD is met. The BG is responsible for paying the FDL. Form 400, MN First Day Liability, is used to inform the member or the provider of the FDL amount for which the member is responsible.

If a member submits a medical expense after the expiration of the budget period, the bill can be used to meet or adjust the SD for the expired budget period only if it is submitted within three months of the expired period, unless Good Cause exists.

If the bill is submitted in the fourth month after an expired FM-MN budget period and Good Cause does not exist, the bill can be used to meet a current or future SD if a BG member continues to be legally obligated to pay it and there is no TPR for that bill.

If an AU member becomes eligible for another Medicaid COA while the FM-MN case is in suspense status, terminate the FM-MN case and approve the AU member for the other COA.

A woman whose medical bills meet SD the day after the day the pregnancy terminates is not eligible for Medicaid as a pregnant woman.

The Newborn does not qualify for NB Medicaid.

A pregnant woman who applies for FM-MN and whose medical bills meet SD on or before the day of the termination of pregnancy can be eligible for Medicaid through the month in which the 60th day from pregnancy termination occurs. Refer to 2720 Continuous Coverage For Pregnant Women .

FM-MN Medicaid begins on the Begin Authorization Date (BAD), a specific day during the budget period.

Medical expenses incurred prior to the BAD in a budget period are not paid by DCH.