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State of Maryland Medical Assistance Manual Revised April 2014

o that was denied due to a technical factor;

o that was denied due to excess resources; or o that expired more than six months after the application month.

• If the LTC provider needs to submit a claim more than 12 months after the service date due to agency (DHMH/DHR) delay or a change in the recipient’s available income calculated by the agency, the CM sends the DHR/IMA 81 Administrative Error Letter to the provider and a copy to the recipient. The provider submits the DHR/IMA 81 letter with the claim, so that DHMH will not apply the 12-month billing limitation when processing the claim.

Example 1: Customer files a MA-LTC application January 3, 2010. No information is returned to determine eligibility. On the 30th day the application is denied and notice is sent to all required parties. The application is placed in a preserved status for the remainder of the 6 month consideration period, which ends June 30, 2010. On July 6, 2010, the customer submits a new application for MA-LTC coverage. The customer states that they have unpaid medical bills for 3 months prior to the month of the new application. Since these bills were incurred during a prior expired consideration period, they cannot be considered for retroactive coverage in connection with the new application. However, the bills must be submitted to DHMH for a determination of the request for deduction of non-covered medical or remedial services.

Example 2: DHMH approves a deduction of $450 for dental care received by a recipient. According to the MAFI screen for the current month (based on the CM’s entries on UINC, ERN1, and ERN2 screens), the recipient’s total available income before deducting these non-covered services is $1,400. The recipient has no deductions for Medicare premiums or private health insurance. After the deduction for non-covered dental services, the recipient’s available income is reduced to $950. The CM enters $450 under “UNCVRD MED AMT” on the INST screen for the month the request was submitted. The CM checks the MAFI screen for the current month. The CM makes the necessary corrections if MAFI does not have $450 for “Non-covered Med Exp” and $950 for the “Available Income Amt.” The CM ensures that the non-covered service is only deducted for the applicable month, not for ongoing months when the available income should return to $1,400. The CM suppresses the CARES change notice and issues the DHMH 4240 (LTC) change notice and the OES 011 (LTC) and DHMH Non-Covered Service Report to the recipient, representative (if applicable) and the LTC facility, to inform them of the recipient’s approved deduction for the dental expense and of the change in the recipient’s available income for the cost of care for that one month. The CM fully narrates in CARES.

Example 3: DHMH approves a deduction of $9,000 for nursing facility services received by a newly approved recipient during two ineligible months prior to the month of application. The CM uses the DHMH 1159D work sheet to re-calculate the available income. The recipient has monthly income of $1,400 and deductions for a personal needs allowance of $74, a spousal maintenance allowance of $400, and the Medicare Part B premiums of $96.40 for the first two months of Medicaid eligibility. Therefore, the recipient’s available income is $829.60, before deducting nursing facility non-covered services. This means that, for the 1st and 2nd month of current eligibility, the deduction for non-covered services (the unpaid private-pay nursing facility bills) is $829.60 and

Rev. 10/2013

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