Medicaid Policy
Medicaid Policy
Introduction
Residents of medical institutions and certain waiver recipients may owe a payment to receive Medicaid services for long-term care. Medical bills the member must pay can be used to meet or reduce this payment. There are some limitations about what medical bills may be used. This policy sets forth the rules on using medical bills for a long-term care recipient.
A. Medical Expense Rules for Long-Term Care
Medical bills must meet the criteria for allowable medical bills found in 461-5 and 461-6. Health insurance premiums a member pays will reduce the contribution, or spenddown. See 431-1.3. In addition, the following criteria applies to medical bills for long-term care recipients.
1. The member must receive the medical service.
· Do not use the medical bill if it is for a family member of the member.
2. The member must be obligated to pay the bill, or some portion of it.
· Allow the expense if it is unpaid at the first of the month and owed to the provider. A service received and paid during the benefit month is unpaid at the first of the month.
· Allow only the portion the member is obligated to pay.
3. Do not allow any incurred medical expenses (bills Medicaid will pay) for a resident of a medical facility who must pay their contribution to that facility. This is because Medicaid eligibility begins on the first day of the month. Medicaid will pay bills for covered services (incurred in that month). Do not use them to reduce the member's contribution to cost of care.
· An individual who has a hospital stay before entering a long-term care facility may use incurred bills only for the month of the hospital stay. See below for rules dealing with Medicare covered bills.
· For HCB waiver recipients, incurred medical bills may be allowed because eligibility is not effective before the member pays their contribution or spenddown to DWS.
· An HCB member who has incurred medical bills must meet the full contribution, or spenddown, with medical bills (incurred and deductions). Incurred bills cannot be combined with cash.
4. To reduce the contribution to cost of care, allow medical deductions for medically necessary services Medicaid will not pay.
· The member may send proof of medical deductions for services received during the benefit month. If it is an allowable medical bill and the member has already paid the bill, reduce that month's contribution to cost of care. Notify the nursing home that the contribution has gone down, as they must refund the member.
· If the medical deduction will be unpaid at the first of the following month, it can be used to reduce the contribution for that future month instead of reducing the current month contribution. Notify the member and the facility.
· Allow the deduction through the month it has been fully used, or the month it is paid in full, whichever comes first.
5. Do not use any bill in the benefit month that has been paid in full before the first day of that month. This includes bills paid by a third party or a family member.
· For applicants, allow expenses paid in full during a retroactive month only in that month. Do not allow it in any later month.
6. Do not allow unpaid long-term care expenses (i.e.: nursing home per diem or HCB waiver services) that the member received while restricted from receiving long-term care Medicaid to meet or reduce a cost-of-care contribution after the restriction ends.
7. Do not allow payments for private-pay days in a nursing facility made in the month a member becomes Medicaid eligible.
· Once the member is determined eligible, the agency will calculate the member's contribution to the nursing facility for the month.
· The member is only required to pay the contribution amount the agency calculates.
· The facility must refund any payments the member already made for private-pay days that exceed the contribution amount.
NOTE: If the member was under a penalty period or restriction for part of the month, the facility will charge them for those days. Do not allow any of those expenses to reduce the member's cost of care contribution.
B. Medicaid for Members receiving Ancillary Only Services
Some nursing home and HCB waiver members may receive Medicaid for ancillary-only services. This occurs when a penalty period applies due to a transfer of assets for less than fair market value. It also occurs when a member has substantial home equity. Both situations prevent the individual from receiving long-term care services (nursing home or HCB waiver services.) These individuals will generally qualify for regular spenddown Medicaid to cover other costs. Medicaid will not pay for their long-term care services.
Ancillary services include visits to medical practitioners (doctors, Physician Assistants, nurses, specialists), labs, therapies, pharmacy (if the member is not on Medicare), etc.
Apply the following rules to reduce or meet the spenddown when a member would have been eligible for long-term care services, but is only eligible for ancillary services.
1. Allow unpaid medical expenses for services received in months before Medicaid eligibility.
a. The expense must meet all the criteria for medical expenses defined in Sec. 461-5 and 461-6.
b. The expense must be for services the member received.
2. Allow the nursing home per diem at the Medicaid rate for the individual as a medical deduction to meet spenddown. If the per diem exceeds the spenddown, the balance will carry forward to the next ancillary Medicaid month.
3. Use expenses paid in full only in the month of payment.
4. Allow incurred medical expenses for services received in the benefit month. The services cannot be payable by a third party, including Medicare.
a. When a member has Medicare or other health insurance, allow only the portion the member is obligated to pay. This may include deductibles or copayments. (461-7)
· If the member has full QMB (Qualified Medicare Beneficiary) coverage, the member does owe any deductibles or copayments for Medicare covered bills.
b. Do not allow Medicare Part B premiums as an expense. When the member meets the spenddown, the state will pay the premium.
c. Once the member meets the spenddown, do not carry any portion of an incurred expense forward to any other month. This is because Medicaid will pay any portion not used to meet the spenddown, (except for the nursing home per diem or waiver specific services withheld due to the penalty or restriction period).
C. Using Expenses After the Penalty Period
The following rules apply to members after the penalty period for transferring assets ends, or after they no longer have substantial home equity and the restriction ends.
1. Do not reduce a member's cost-of-care contribution with bills for any of the unpaid long-term care services the person received during the penalty period for asset transfers or the restricted period due to substantial home equity. This includes the nursing home per diem and long-term care services the HCB waiver Medicaid program would have paid.
· Some portion of these bills may have been used to meet the spenddown during the ancillary Medicaid months. However, do not allow any of the unused, unpaid balance to reduce a future cost-of-care contribution after the penalty or restricted period ends.
2. After the penalty period ends, do not allow as a medical deduction, medical bills the member incurred during months the member was eligible for Ancillary Medicaid.
· Medicaid will pay for medical services that meet the definition of incurred expenses when the service is received in a month the member was eligible for Ancillary Medicaid.
· If the member did not meet a spenddown to receive Ancillary Medicaid, allow unpaid medical bills from ineligible months as a medical deduction to reduce the cost-of-care contribution.
i. Do not allow bills for the excluded long-term care services.
ii. The bills must be owed to the provider and not payable by a third-party.
3. Do not allow any medical bills used to meet a month's spenddown in any later month even if it remains unpaid.
· Allow the unpaid portion of a bill not used to meet the spenddown only if the bill meets the definition of a medical deduction, is still owed to the provider and is not payable by a third party.
· Do not allow any of the unpaid long-term-care bills to meet a cost-of-care contribution.
4. New Choices, Community Transitions and Physical Disabilities waivers – Exception for Spenddown Coverage Group
New Choices, Community Transitions and the Physical Disabilities waivers have a spenddown coverage group. The following rules apply to a member who becomes eligible under the spenddown coverage group after having been in a coverage group subject to a penalty period or a restriction period. These rules do not apply to other HCB waiver recipients.
· When a member whose long-term care services were restricted now qualifies for the spenddown group under one of these HCB waivers, the following exception applies.
i. Allow as a medical deduction, the unpaid portion of long-term care services received during the restricted period to meet the individual's spenddown.
ii. Allow only the portion not already used to meet a spenddown in a previous month.
iii. The expense must still be owed to the provider and not payable by a third party.
D. Nursing Home Costs Before the Medicaid Effective Date
If an applicant was institutionalized before the effective date of Medicaid coverage, and was not restricted from Medicaid for long-term care services, the member may have unpaid private-pay days.
1. Allow unpaid costs for private-pay days that occurred before the effective date of Medicaid coverage to reduce the current month's cost of care contribution. The bill must meet both of the following requirements.
· The charges must be the member's obligation to pay, meaning no third party will pay them.
· The charges cannot be for long-term care services accrued during a penalty period for transfer of assets, nor during a period when Medicaid is restricted due to substantial home equity.
2. If the individual becomes eligible for Nursing Home Medicaid for any of the retroactive months, the member will only owe the cost-of-care contribution determined for that month.
· Do not deduct payments for private-pay days the member paid in a retroactive month as a deduction from that month's cost-of-care.
· The nursing home must refund private payments made by the member for that month to the extent they exceed the cost-of-care contribution for that month.
E. Medicare Copayments for Long-Term Care
A nursing home resident may receive nursing home services covered by Part A Medicare. Some days may require a co-payment from the resident.
1. If the person is open for community Medicaid or QMB during the month, Medicaid or QMB will cover the co-payments incurred.
· The resident will not owe the co-pays.
· Do not allow these copayments as a medical expense to meet a cost-of-care contribution in any month.
2. If the resident is not eligible for Medicaid or QMB during one or more months of Medicare co-pay days, deduct the unpaid copayments in a future Medicaid month.
· This does not apply if the member was under a penalty for asset transfers or substantial home equity in the month services are received. Do not deduct those Medicare Part A copayments from any month's cost-of-care contribution.