INELIGIBLE OUT-OF-POCKET EXPENSE

When it is determined the participant did not did not pay for an eligible medical expense the eligibility specialist will:

Complete the IM-29OPE, noting No to eligible expense and the reason not eligible. (If expenses are provided for more than one month, complete separate forms for each month.) Make one copy of the form.

Mail the original to the participant and file one copy in the IM case record.

Do not send the IM-29OPE for ineligible medical expenses to the ES supervisor or the regional policy liaison.

EXAMPLE: Mrs. Moore paid her September 2011 spend down invoice of $158. On January 5, 2012, Mrs. Moore provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was an explanation of benefits from the participant’s Part D plan dated 9/2/2011, which stated what the “plan paid” and what you paid”, in addition to “other payments made by programs or organizations.” There was no accompanying verification from the pharmacy used to indicate that participant had actually paid the co-pays.

This is not an eligible out-of-pocket request for two reasons which the eligibility specialist recorded in the appropriate section of the IM-29SPDN:

September dates of service could offset October, November and December invoices. The documentation wasn’t received until January 5, 2012 therefore it could not be applied to October, November and December invoices, and

The documentation provided did not verify the participant had actually paid the pharmacy co-pays.

EXAMPLE: Mrs. Plano paid her October 2011 spend down invoice of $136. On January 06, 2012, Mrs. Plano provided some documentation to the eligibility specialist that she wanted to apply to out-of-pocket expenses. The documentation provided was a statement from her doctor’s office which indicated a balance due of $21.19. The itemization indicated the $21.19 expense was from a date of service 05/13/11. There was additional itemization reflecting charges of $95 on 10/14/11, an adjustment of $27.95, and a payment of $67.05.

These are not eligible out-of-pocket expenses for the following reasons, which the eligibility specialist records in the appropriate section of two separate IM-29OPE forms. Two IM-29OPE forms are required as it is two different services dates in different 3 month periods.

A date of service of May 13, 2011, could offset June, July and August invoices. As these months have passed, the out-of-pocket expense cannot be applied to offset June, July, or August invoices.

A date of service of October 14, 2011, could offset November, December, and January. Although documentation for the date of service of October 14, 2011 could be used to offset January invoice, it is unclear what the adjustment was for and who paid the $67.05 and what amount if any Mrs. Plano paid.