Allowable Medical Services and Expenses used to reduce participation and MN spenddown

	Search for:

DSHS Home Acronyms Revisions WAC Number Index Site Map WCCC

Revised March 15, 2012

Medical Deductions-Long-term care

Purpose: This section gives a listing of allowable medical or remedial services and expenses that are allowed to reduce participation or used in MN spenddown. This is not a complete list, but an aid to use when to determine whether a claimed medical expense is allowed to reduce participation or used to meet spenddown.

Practitioners

Allowable Practitioners

- M.D. Physicians	- Opticians
- D.O. Osteopaths	- Pharmacists
- D.D.S. Dentists, Denturists, Orthodontist, Periodontists	- ARNP Advanced Registered Nurse Practitioners
- D.C. Chiropractors	- Psychologists/Psychiatrists
- P.A. Physician Assistants	- CRN Certified Registered Nurses
- D.P.M. Podiatrists	- Midwives
- O.D. Optometrist	- X-ray technicians
- Dental Hygienists	- Electrotherapists
- Hydrotherapists	- Inhalation/Respiratory therapists
- Licensed practical nurses	- Occupational therapists
- Physical therapists	- Speech therapists

Allowable Practitioners with a Documented Referral from an M.D., D.O.,

D.D.S., OR A.RN.P.

- Acupuncturists	- Dieticians
- Naturopaths

Non-Allowable Practitioners

- Herbalists	- Homeopaths
- Holistic Healers	- Hypnotists
- Masseurs or manipulators	- Psychic or faith healers
- Sanipractors	- Veterinarians (unless the expense is for a medically necessary service animal)
- Practitioners not recognized under WA State Law	- Medical Marijuana Distributor

Expenses, Services and Supplies

Allowable expenses

- Medical supplies (eg syringes, adult diapers etc) and drugs, including OTC drugs prescribed by an M.D., D.O. or A.R.N.P.	- Cost of, or payments if rental or purchase contract for durable medical equipment, including aids to mobility, rehabilitative aids, prosthetic/orthotic devices and Electronic Emergency Response Systems (EERS)
- Hospital services, emergency room, clinic (including mental health clinics) and nursing facility expenses	- In home nursing care if need is documented with a physician’s statement
- Insulin and its necessary administration devices	- Blood and its derivatives
- hearing aids and related supplies	- Oxygen
- Medical/dental insurance premiums, deductibles & coinsurance charges incurred during the base period.	- Out of State billings for medical services recognized under WA State law.
- Remedial care such as dialysis helpers	- Community case management in support of medical services or care
- Medical transportation by personal vehicle at the current state reimbursement rate.	- Medical transportation by other means at the actual fare or fee. May include parking fees
- Medically necessary improvements to the home to accommodate a disabled person	- Other services prescribed by an allowable medical practitioner
- Away from home lodging costs related to medical treatment	- Food and other expenses for a medically necessary service animal

Non-allowable expenses

- OTC drugs & medications not prescribed	- Out of State billings for medical services not recognized under WA State law.
- Services obtained out of the US	-Special diets - Nutritional supplements unless prescribed such as enteral liquid and powdered supplements that are medically necessary. For LTC programs liquid supplements that are medically necessary are covered by Medicaid. Liquid supplements (enteral supplements) not approved by HRSA are not considered a medical expense to be used to reduce participation.
- In home cooking/cleaning services	- Property maintenance
- Trips or retreats	- Health camps or retreats
- Sex change operations	- Dietetics
- Commercial diet clinics & gyms	- Telephone charges
- Physical fitness aids unless prescribed for medical services	- Unpaid LTC participation incurred while active on an institutional medicaid program
- Private alternate living facility (ALF) charges are not considered a medical expense. See WAC 388-513-1305 for possible eligibility of Medicaid using rules for individuals living in state contracted ALFs.	- Insurance premiums for policies that pay a cash benefit to the insured and the benefit is not intended to reimburse a provider. These premiums are not health insurance but pay directly to the insurance holder under certain conditions. (usually a daily rate when the client is unable to work, in the hospital or has a certain type of medical condition). You may need to contact the carrier to find out if it is a health insurance or one of these policies that pay a cash benefit to the client and not a provider because of a health condition. This does not include LTC insurance. LTC insurance premiums are an allowable deduction. Most LTC insurance policies waive the premiums when the client needs the benefit of LTC insurance.
Medical Marijuana. Cannabis is not an approved prescription drug under Federal Food, Drug and Cosmetic Act and not been approved by the FDA for treatment.

Medical expenses and MN Spenddown

This section includes some of the main points of MN Spenddown.

MPA Medical Spenddown Allowable Expenses Chart

For more information on Medical Spenddown such as base periods, medical transportation, public programs and ACES screens see Medical Assistance-Spenddown

Incurred Medical Expenses

Before medical expenses can be used to reduce or meet spenddown, the client must have incurred the legal obligation. This means that the client must have received the medical service or product and have a legal obligation for the cost.The medical expenses used to meet spenddown are the clients’ obligation and cannot be billed to Medicaid.

Medical insurance premiums are always treated as income deductions and are not applied to Spenddown with the exception of all Medicare premiums (this includes Medicare C advantage premiums). The Department allows insurance premiums as an income deduction. When the client meets spenddown, the department determines if it is cost effective to pay the premiums to ensure the coverage continues. If it is cost effective and the client meets spenddown, the Department pays the premium. If the client does not meet spenddown, the department does not pay the premiums.

Medicare premiums are paid by the department. It takes approximately two months before the department begins paying when there has been at least a 30 day break in the client's medical benefits.

For questions related to insurance or Medicare premium payments, contact HCA Coordination of Benefits section at 1-800-562-3022 EXT: 1-6129 or e-mail at https://fortress.wa.gov/dshs/p1contactus/ If using the the contact us e-mail, use the client button. Indicate your contact information and question. Indicate you are a financial worker and your office. Include the ACES client ID.

DSHS no longer pays Medicare C premiums with the exception of a small existing caseload subject to funding (these cases were grandfathered for Medicare C payment).

CMS guidance on Part D prescription drug expenses and spenddown.

NOTE:

LTC medical expenses are indicated on the LTCX screen. The MEDX screen is used for recipients on other programs such as food assistance. Make sure the medical expense is indicated on the LTCX and MEDX screen when a LTC recipient is on food assistance.

Medical Expenses specific to long-term care

WAC 388-513-1350 (7) (d) gives the criteria for allowable medical expenses used to reduce excess resources. DDD Waivers, HCS CN Waivers, Hospice and participation rules point to this WAC as to allowable medical expenses.

Premiums, deductibles, and co-insurance/co-payment charges for health insurance and Medicare premiums
Necessary medical care recognized under state law, but not covered under the state's Medicaid plan;
Necessary medical care covered under the state's Medicaid plan incurred prior to Medicaid eligibility.
As long as the incurred medical expenses:
- Are not subject to third-party payment or reimbursement
- Have not been used to satisfy a previous spend down liability
- Have not previously been used to reduce excess resources
- Have not been used to reduce client responsibility toward cost of care
- Were not incurred during a transfer of asset penalty described in WAC 388-513-1363, 388-513-1364, 388-513-1365 and 388-513-1366;
- Are amounts for which the client remains liable.
Expenses not allowed to reduce excess resources or participation in personal care are:
- Unpaid expense(s) prior to Waiver eligibility to an adult family home (AFH) or boarding home is not a medical expense.
- Personal care cost in excess of approved hours determined by the CARE assessment described in 106 WAC is not a medical expense

Rules on HCS MN Waivers can be found at:

Medically needy income waiver (MNIW)

Medically needy residential waiver (MNRW)

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

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

There are some exceptions 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 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 HRSA 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.
- Healthcare coverage-scope of covered categories of service. (Scope of care WAC and chart).
- Healthcare coverage-Description of covered categories of service.
- Healthcare coverage-Noncovered services.(Noncovered by Medicaid)
Liquid supplements (such as Ensure, Resource) are covered by MPA Medicaid when medically necessary. Liquid supplements (enteral nutritional products) not approved by MPA are not considered a medical expense used to reduce participation even if the client has a medical prescription.

EXAMPLE

LTC client with participation chooses to see a doctor that does not have a Medicaid contract. This expense would have been covered under Medicaid. The department does not reduce participation by a private rate expense that would have been covered under the Medicaid program.

There are exceptions to the example above.

There are situations where a needed provider is not available within a reasonable distance. If we do an exception, the reasoning has to be documented. We do not allow a medical expense at a private rate if the care/expense is available at the Medicaid rate.

EXAMPLE

Many dentists do not accept Medicaid. There are areas in the state where there isn't a Medicaid provider located within a reasonable distance. We will allow a dental medical expense if the client is unable to find a provider to accept medicaid or cannot reasonably travel to a dentist that accepts medicaid. Make sure this is carefully documented behind the LTCX screen.

NOTE:

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.

Medical expenses and room and board

Necessary medical expenses are an allowable deduction to determine the client's participation. For Waiver clients residing in alternate living facilities, it is not an allowable deduction without an exception to rule (ETR). No deduction is allowed from room and board without an ETR.

Submit an ETR request to the HCS regional designee for a medical expenses that would have been used to reduce participation if there had been available participation.

Room and board for general assistance recipients is not reduced by medical expenses. Do not refer GA cases for an ETR.

Reducing room and board is the last resort as it is state funded. If the expense can be deducted through participation, but takes a few months because of low participation, use that method rather than an ETR to reduce room and board.

See: HCS Waivers, Room and Board, ETRs and Bed holds.

DDD Waiver also use a method to reduce room and board for necessary medical expenses and guardianship fees. DDD has authorized the case manager as the designee to approve these costs from room and board.

Any deduction from room and board must be coded as an ETR in ACES.

LTC and Medicare C and D charges

Medicare Programs describes Medicare programs, buy-in, Medicare buy-in unit contact information, what is Medicare and the different Medicare programs. This includes information on Medicare A, B, C and D and referral numbers for help on Medicare related issues.

CMS guidance on expenses related to Medicare D for spenddown

Medicare and Long-Term Care link has detailed information on Medicare and long-term care including participation issues.

TPL, COB, Premium Assistance program

Medical Assistance-Third party liability

This link describes third party liability, coordination of benefits and instructions on the premium assistance program with HRSA.

Expenses of a medically necessary service animal

A description of service animals is described in WAC 388-473-0040 food for service animals as an ongoing additional requirements. Although this section describes when to authorize food for services animals of an SSI or TANF recipient, it can also be used as a guideline when determining if expenses related to a service animal can be used as a medical expense.

In order for expenses related to a service animal to be used as a medical expense:

Consult CARE and the client's social service specialist/case manager as to whether the service animal is medically necessary. If the social service specialist is unable to determine if the service animal is medically necessary get a statement by the client's physician/practitioner as to why the expense is medically necessary.
The service animal must be performing a task that is necessary for the health and safety of the individual.

For LTC recipients with service animals that are on SSI, consider food for service animals as an ongoing additional requirement. If authorized, do not allow the food as a medical expense to reduce participation.

ACES and Medical Expenses

LTCX screen used in institutional medicaid programs to indicate medical expenses.

MEDX screen used to indicate health insurance premiums for spenddown. Used to indicate all medical expenses for food assistance.

SDME screen used to indicate medical expenses for spenddown.

ACES-LTC

ACES-Medical expenses as a deduction