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3. If the a/b has Medicare and private health insurance which covers physician costs (medical), do not make any deduction unless there is a balance left after insurance has paid. Use EOB as verification.

4. If the a/b has private health insurance but not Medicare, only deduct the portion of the charge not covered by insurance. Verify with EOB or from provider.

D. Cost Of A Private Duty RN/LPN Charges for private duty RN/LPN services may be deducted as UMN if the physician prescribed this care for a specific duration, the nurse refuses to accept Medicaid, and the criteria in VIII. A., above is met.

E. Cost of The Nursing Facility When Medicaid Is Authorized After the First Day of the Month It may happen that the a/b is not eligible for Medicaid to pay cost of long term care on first day of month, but later in the month becomes eligible. This could happen when the a/b is ineligible for cost of care for a few days because of reserve or the facility is not yet certified. Specific rules to use nursing facility costs as UMN are listed below.

1. Deduct per diem cost of care as an unmet medical need if a/b resides in a newly licensed/certified facility and cost of care is paid from income for the days in the month of certification, but prior to the certification date and all of the following are true:

a. The rules in VIII.A., above, are met (note that VIII.A.2.b. states if Medicaid does not pay for LTC due to a transfer of assets sanction, those LTC expenses may not be an unmet medical need), and

b. The a/b has an approved FL-2/MR-2 for the level of care.

2. The a/b may be ineligible for a portion of a month due to excess reserve.

a. Do not allow cost of care as an unmet medical need when the a/b uses their excess reserve to pay cost of care. (1) Payment of cost of care "in advance" does not reduce reserve any earlier than the date the cost(s) is incurred. Actual charges are deducted from the reserve total on a daily basis as incurred. (2) On the day that reserve is reduced, assign the full PML for the remainder of that month.

b. You can allow cost of care as a one-time UMN if excess reserve is reduced by purchasing other goods or services and cost of care is paid from income for the month in which reserve is reduced. F. Charges for Medical Care During an Ineligible Period Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493