When to allow medical expenses

Changes including medical expenses must be reported within the timeframes outlined in WAC 182-504-0110 . Changes that must be reported will be used for all medical including institutional medical programs. See WAC 182-504-0105 .

If a medical expense is not reported within required time frames, we are not able to use the expense as a post eligibility deduction for institutional Medicaid. For HCBS Waiver, we may allow a medical expense if unpaid as long it meets the criteria in WAC 182-513-1350 (6) and (7).

If a medical expense increases and is not reported within time frames, we can't go back historically and change the amount. If a medical expense ends, (such as a health insurance premium), and it is not reported timely, it is an overpayment.

In order to allow a medically necessary noncovered item, we will need verification:

Of the cost

Item is prescribed by an allowable practitioner and is considered a medically necessary item

Item is not covered by Medicare, Medicaid, or Apple Health managed care. Most medically necessary items should be covered for individuals receiving long-term care. Any item indicated on the pharmacy covered list , including over the counter items such as cough/cold medications or vitamins cannot be allowed as a participation deduction.

For medical equipment and supplies (MES) or environmental modifications, check with the social worker/case manager as to whether it should be covered under the HCBS waiver? Most MES is covered under the Medicaid scope of care or HCBS waiver. HCBS MB H13-030 dated June 24, 2013 has more information regarding MES vendors.

If the reported expense appears to be covered, send a letter explaining why the expense is not allowed using the text templates that include the rule.

Send the medical expense fact sheet to all new openings and clients that turn in expenses that are not allowed as a participation reduction.

Noncovered allowable medical expenses. Differences in how we apply the medical deduction in institutional medical and HCBS Waiver

Once it is determined the medically necessary expense is allowed as a deduction, there is differences in institutional and HCBS Waiver cases on when we allow the medical deduction.

Post eligibility participation ( WAC 182-513-1380 , WAC 182-515-1509 , WAC 182-515-1514 )

There are three methods of allowing expenses in post eligibility described in WAC 182-504-0120 (11) for institutional programs and WAC 182-504-0120 (12) for HCB Waivers. Federal guidance allows Method 1 or Method 2 for institutional cases (those residing in medical institutions). Federal option allows Method 3 for HCBS Waivers.

Method 1: Allow the expense in the month it was incurred; or

Method 2: Estimate medical expense incurred in the preceding period, not to exceed 6 months if the expenses are expected to continue. At the end of the prospective period, or if there is a significant change of 25%, the expense is reconciled for the next time period. A reconciliation is required, at least every 6 months when using Method 2. Use barcode ticklers to track the expenses and reconciliation period. Use the Method 2 training instructions and calculator and document that Method 2 is being used to estimate medical expenses.

Method 3: When there is a change in income, or allowable expenses, that changes the amount of the cost of your care for a home and community-based waiver or service, we calculate the new participation amount effective the first of the month following the date the change was reported, except that the new participation amount will be effective the month the change occurs if the change is the loss of an income source that you report within thirty days of the change.

For additional information on Method 1, Method 2, and Method 3 go to the financial SharePoint site. See financial training under the policy and program changes.