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Louisiana Medicaid Eligibility Manual Eligibility Determinations Reissued July 18, 2025 Page 12 of H-1040 Replacing July 31, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

$4,000.00 -$1980.00 Incurred Medical Expense – Dental – Date of Service January 13th. $2,020.00 -$1926.30 Prorated Medicaid facility rate for 15 days $93.70 Spend-down not met in LTC SD MNP

Continue eligibility review for LTC SD MNP/Income over Facility Fee

$4,171.10 Excess income - 171.10 Medicare premium $4,000.00 -$1980.00 Incurred Medical Expense – Dental – Date of Service January 13th. $2,020.00 -$2025.00 Private payment charges for 15 days $0.00 Spend-down met in LTC SD MNP/Income over Facility Fee for January.

If the remaining income is $0.00, the individual has spent down and is eligible for LTC SD MNP/Income over Facility Fee. ** There is no vendor payment for LTC SD MNP/Income over Facility Fee certifications.

** Complete a Form 110-MNP when there is an incurred medical expense on the effective date of the coverage for LTC SD MNP/Income over Facility Fee certifications. Refer to MEM H- 1041.8 Form 110-MNP.

If there is remaining income after allowable incurred medical expenses have been considered in the budget process, the applicant/beneficiary is not eligible for Medicaid.

D. Determination of Countable Resources

Determine eligibility with regard to resources:

Determine total countable resources of the applicant/beneficiary. Refer to I-1630 SSI-Related Resources

If the applicant/beneficiary has a community spouse, refer to I-1660 Spousal Impoverishment Resource Provisions.