Family and Children's Medicaid MA-3315 MEDICAID DEDUCTIBLE

II. HOW TO MEET A DEDUCTIBLE

A. When Deductible Is Met

1. The deductible is met on the day that the total of medical expenses applied to the deductible equals the amount of the deductible for the certification period. Refer to MA-2240, Transfer of Assets, in the Aged, Blind, And Disabled Medicaid Manual to determine when the CAP indicator is entered for CAP applicants/recipients subject to a deductible and a sanction period.

2. The inpatient hospital admission of a Medicaid a/r (who does not have Medicare Part A coverage) is assumed to meet the deductible on the date of admission, regardless of length of stay or the ultimate amount of charges. (See III. B.)

3. The inpatient admission of an individual under age 21 to a Psychiatric Residential Treatment Facility (PRTF) is assumed to meet the deductible, regardless of length of stay, the ultimate amount of charges, or Medicare coverage. PRTF admissions are not covered by Medicare.

B. Whose Bills to Apply to the Deductible

1. Apply medical bills of any budget unit member.

2. Examples:

a. An individual, age 20, is certified for M-AF. He lives with his able-bodied parents. The b.u. is three persons. Medical expenses of the 20 year old and his parents are counted toward the deductible.

b. A child, age 15, lives with his mother. Both apply for M-AF. The budget unit is 2 and their countable income exceeds 200% of poverty. Medical expenses of both the child and the mother apply to the deductible.

REVISED 01/01/09 – CHANGE NO. 02-09

(II.B.2.)

c. A child, age 19, lives with his mother and his two siblings who are under age 6. The mother’s countable income exceeds the MAF-CN income limit, but is under 133% of poverty. The two younger children are eligible for M-IC. The mother and the 19 year old child apply for M-AF. The budget unit is the mother and the 19 year old child. Only their medical bills apply to the deductible. The two younger children are in the needs unit, because the mother is financially responsible for them. However, only bills of those in the budget unit may apply to the deductible.

C. Allowable Expenses

Charges which may be applied to the deductible include, but are not limited to, the following:

1. Medically related services recognized by state tax law;

2. Services covered by NC Medicaid;

3. Professional medical services provided by physicians, dentists, therapists, hospitals, clinics, laboratories, or other providers of medical services, including cost of care in approved level in nursing facilities during pla deductible month;

4. Prescribed medications, over-the-counter non-prescription drugs, and medical supplies, such as aspirin, cold medicines, alcohol, bandages, absorbent pads for the incontinent, and injection syringes and needles, etc.;

5. Medical services incurred during a prior authorized period that are not covered by Medicaid or that are in excess of the allowed coverage (e.g., prescriptions in excess of 6 per month, eyeglasses replaced in less than 1 year, etc.), provided they remain unpaid (see III.A.1.);

6. Medically related transportation (actual cost or .25 per mile);

7. Medical equipment, such as eyeglasses, hearing aids, dentures, crutches, braces, etc., that are not paid by Medicaid or other insurance;

8. Health insurance co-payments and deductibles, if not covered by any other third party, and Medicare Part B premiums through the first month of Medicaid authorization; and

9. Private health insurance premiums if the a/r will not be reimbursed.

a. Health insurance premiums are incurred on the date the payment is due regardless of what months or period of coverage the premium covers.

b. Do not prorate premiums for more than one month of coverage to a monthly amount.

c. Insurance premiums cannot be “rolled over” to a subsequent c.p. UNLESS the premiums are unpaid and meet the requirements for bills incurred prior to a current c.p. (See III.A.1)

REVISED 01/01/08 – CHANGE NO. 01-08

(II.C.9.)

d. If health insurance premiums have been deducted from earned income either as a standard or actual work-related expense, do not apply the cost of the premiums to a Medicaid deductible.







For questions or clarification on any of the policy contained in these manuals, please contact your local county office.