What are the differences between expenses allowed to reduce participation and those used in medically necessary (MN) spenddown?

The medical expense chart used for MN spenddown is the same basic guideline used to reduce participation for LTC programs.

There are situations that are unique to long term care programs.

Expenses incurred during a LTC transfer penalty are not allowed to reduce participation.

For LTC, a medical expense prior to eligibility must be unpaid. For spenddown, expenses incurred and paid 3 months prior to the application can be used.

Private personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense.

Unpaid expenses prior to HCBS Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense. This applies to both participation and MN spenddown. These facilities are not medical facilities. Another term for AFH and boarding homes is alternate living facility (ALF).

Expenses of the community spouse or family members. This includes health insurance premiums. If the health insurance premium is for the couple, we allow one half of the expense for the LTC recipient if we are unable to determine the amount of the LTC recipient's share.

Health insurance premiums paid by a 3rd party including HCA COB unit are not used to reduce participation. Health insurance premiums paid on a client's behalf by COB are considered an income deduction for the MN Spenddown program.

Medical expense deduction from participation that is a covered item under the state plan is not allowed as a deduction if the client was on Medicaid during the date of service.

Medical expense deduction for copayments or deductibles from participation that is a covered item under Medicare is not allowed as a deduction if the client was on Medicaid and QMB during the date of service.

Medical expense deduction from participation that is a covered item under the Apple Health managed care plan is not allowed as a deduction if a client chooses the service outside of the network.

Liquid supplements (such as Ensure, Resource) are covered by Apple Health when medically necessary. Liquid supplements (enteral nutritional products) not approved by HCA are not considered a medical expense used to reduce participation even if the client has a medical prescription.

Effective 11/22/2012 reasonable limits on allowable medical expense deductions described in WAC 182-513-1350 was final. Expenses for nursing facility care are reduced at the state rate for nursing facility care that is owed by the client prior to Medicaid eligibility. It is based on the state rate for the particular facility the bill was incurred. Medical expenses incurred more than three months before the month of application is not an allocable medical deduction to reduce participation.

Expenses allowed only once

If an expense was used to meet a prior spenddown or to reduce excess resources for LTC programs, it cannot be used to reduce participation. This is the same rule as the spenddown program. An expense is allowed once.