Medicaid Policy
Medicaid Policy
A. Medically Necessary Services
Medical bills must be for medically necessary services to be allowed to meet a spenddown or cost-of-care contribution. The following policy defines what constitutes medically necessary.
1. Always consider services covered by the Traditional Medicaid benefit package medically necessary, even if such services are only provided to a limited group of eligible recipients.
a. The member or family member does not have to qualify for Traditional Medicaid.
· For example, member's spouse is not Medicaid eligible, but has bills for physical therapy. The services are considered medically necessary.
b. For a list of Traditional Medicaid covered medical services, see the Medicaid Member Guide at http://health.utah.gov/umb/forms/pdf/Medicaid_Member_Guide.pdf. [The member guide shows which type of Medicaid benefit plan different eligibility groups receive. The plans include Traditional Medicaid with or without dental.
c. The list for covered over the counter medications (OTC Drug List) can be accessed at https://medicaid.utah.gov/pharmacy/resource-library/.
2. Services not covered by Traditional Medicaid can only be used as a medical bill if the service meets the following two conditions:
a. The service is prescribed or given by a licensed medical practitioner; AND
b. The service is usually considered medically necessary.
· Examples of medically necessary services covered for some, but not all, Traditional Medicaid recipients include eyeglasses, speech and hearing services for adults and podiatry services for adults.
· If the benefit plan the member receives does not include some of these services, the medical bills for such services can be used as medical deductions.
Example: An adult on Family Medically Needy receives hearing services in July and hearing aid are ordered. The member wants to meet the July spenddown using the bill for the hearing aids. The hearing aids are a medical deduction because Medicaid does not cover hearing aids for non-pregnant adults on Family Medicaid. Use the expense in July. If the expense is greater than the July spenddown, any remaining unpaid amount can be used in a later month.
3. When a medical service is not covered by Traditional Medicaid, but the service is one that is usually considered medically necessary, allow the bill as a medical expense. This could include a service that exceeds limits set by Medicaid on the duration or amount the state will cover.
· Example: Medicaid may limit occupational therapy visits, but the member's doctor prescribes more sessions. Treat this as medically necessary and allow the charges as a medical deduction because Medicaid will not pay it.
If uncertain whether a service is usually considered medically necessary, ask the DWS Program Specialist to seek approval from DHHS before allowing the bill.
If a member says her doctor will not provide a service because Medicaid will not cover the cost, ask DHHS if the service is considered medically necessary before allowing the expense.
B. Services Requiring DHHS Approval
DHHS must always approve the services listed below because they are not usually considered medically necessary. Seek DHHS approval before using them to meet a spenddown.
1. Pharmacy items not covered by Medicaid, including prescriptions or over-the-counter medications not approved by Medicaid.
· For prescribed over-the-counter medications, go to https://medicaid.utah.gov/pharmacy/resource-library/ to see if they are allowable OTC's. Table III also has a list, but may not be as up-to-date.
2. Supplies that can be used for non-medical purposes, (i.e. air conditioners, food scales.)
3. Convenience items: special pillows, electric beds, hygiene products, etc.
4. Any service received that primarily has a cosmetic or non-medical effect. The service could be a cosmetic surgery, orthodontics for an adult, homeopathic treatment or massage therapy.
5. Abortion performed for any reason except to save the life of the mother, or in the case of rape or incest.
6. Gender change operation.
7. Sterilization for women or men can be paid by Medicaid as family planning services. A person must sign a consent form at least 30 days before the procedure. If conducted in a non-Medicaid month, or for an ineligible family member, contact DHHS for approval before allowing the expense.