Certain paid and unpaid medical expenses for members of an applicant/recipient group may be deducted from income when determining on eligibility for NMP. Allowable medical expenses can be used to lower net income when the income is above the limit for continuing NMP. Allowable medical expenses must be in the retroactive period.
Reminder: When figuring net income, the CAO must deduct expenses for medical and remedial care for members of an applicant/recipient group that are paid by a public program (other than MA) of a state, including programs run by political subdivisions of the state.
NOTE: A medical expense that was deducted when deciding on eligibility for MA cannot be deducted again. For information about medical expense deductions for MA, see Appendix B.
There is no spend-down for retroactive NMP.
An unpaid medical expense is an allowable deduction if the following conditions are met:
The expense is not paid by a third party.
NOTE: When legal action is being taken for third-party coverage (for example, a workers compensation claim has been filed) and the case is not likely to be settled within 30 days, the coverage cannot be considered available for payment of individual’s medical bills. The medical bills can be considered an unpaid expense, and a deduction can be given for those medical bills. When the legal action is settled, if the third-party coverage is approved, the CAO must treat the approval as a change in the individual’s situation. It must reconsider the individual’s MA eligibility and send information about the case and the third-party coverage to:
Third-Party Liability
P.O. Box 8486
Harrisburg, PA 17105
The expense must not be paid under the NMP program, if NMP is approved.
A member of the applicant/recipient group is required by law to pay the expense
.
NOTE: The medical expense may be for someone other than a member of the applicant/recipient group. The CAO must use the expense only if a member of the applicant group is held legally responsible for payment.
The amount and the date of the expense are confirmed.
NOTE: For medical insurance premiums, the date of the expense is the date when the bill was paid.
The expense was not already used as a deduction for MA eligibility.
A payment plan is not required, but the individual must show proof that the bill has not been written off by the provider and payment is still required.
For continuing NMP, the CAO must count unpaid expenses from the retroactive period or unpaid expenses that are expected in the calendar month for which eligibility is being considered.
A paid medical expense is an allowable deduction if the following conditions are met:
The expense was paid by a member of the applicant/recipient group.
The expense was not already used as a deduction for MA eligibility.
The amount and the date of the expense are confirmed.
For continuing NMP, the CAO must use only expenses that are paid in the calendar month for which eligibility is being considered.
The CAO must use the actual medical expenses that were paid in a calendar month.
Example: A quarterly insurance premium can be used only in the month when it was paid.
The CAO must deduct the following medical expenses:
Payments for health insurance which include premiums, enrollment fees, deductibles, and co-insurance charges (such as Medicare, Blue Cross or Blue Shield), and the part of an automobile insurance premium that is for medical coverage
NOTE: The CAO may need to contact the medical provider to find out whether the individual has to pay an entire bill or only the part not covered by Medicare or medical insurance.
NOTE: When deciding on an individual’s MA eligibility, the CAO must deduct any medical insurance premiums through the spend-down process. When a Health Insurance Premium Payment (HIPP) referral results in HIPP covering the premium and the individual’s income is over the income limit for MA, the individual is still eligible, because the insurance premium is still considered a deduction.
Copayments required by DHS.
NOTE: The copayment deduction is subject to the copayment fee set by the DHS. See Chapter 338, Medical Assistance Benefits, Appendix D, for a list of the copayment amounts for medical services.
The payment for each prescription for an individual who is eligible for the Pharmaceutical Assistance Contract for the Elderly (PACE) program.
NOTE: A recipient of NMP cannot be in the PACE program. However, a recipient of NMP monthly spend-down can use the PACE program for the part of the month in which he or she does not get NMP.
Medical and remedial expenses that are recognized by state rules or laws but are not covered by the NMP program.
NOTE: See the Health Care Benefit Packages (Chapter 338, Appendix A) for lists of services that are covered by different categories of MA.
NOTE: Payment for aspirin, nutritional supplements or other over-the-counter drugs can be allowed if a doctor says that the individual needs the drug for a physical or mental condition.
NOTE: Burial and Personal Care Home costs are not medical expenses and cannot be used as deductions when deciding on an individual’s eligibility.
Medical expenses that are covered by the NMP program if:
The individual has already made the payment.
The individual must pay because the medical provider does not accept the medical card.
NOTE: This includes patient-pay amounts from earlier periods of MNO eligibility, if they are in the allowable retroactive period. See Chapter 369, Determining Eligibility for MNO, Section 369.13.
The full cost of services that are paid in part by MH/MR
NOTE: An individual who is eligible for MH/MR services is eligible for payment of services by MH/MR. The CAO must use the full cost of the services as the amount the individual owes or has paid without deducting the part that was paid or will be paid by MH/MR.
Once a medical expense is used as a deduction in figuring out income eligibility, the expense cannot be used again.
If an individual has no or limited medical expenses when he or she applies, the CAO must let the individual know that medical expenses may be "saved" to be used at a time when he or she may have more medical needs. The CAO must allow the an individual to choose the way that will best meet his or her needs or the needs of his or her family.
Only the part of expenses needed to make the applicant/recipient group eligible must be used. The CAO must deduct paid medical expenses, including Medicare and other insurance premiums, before using unpaid expenses. For NMP, paid expenses may only be used in the month paid, while unpaid expenses that are not used when considering eligibility are available for use in a future decision.
NOTE: Allowable medical expenses must have occurred during the allowable retroactive period.
Updated February 14, 2012, Replacing July 24, 2008