Family and Children's Medicaid MA-3315 MEDICAID DEDUCTIBLE
iii. Applying Bills to Deductible
A. Order
1. First, apply a medical expense to a deductible in a current c.p. if it is the unpaid balance of an old bill incurred by a budget unit member. Apply it on the first day of the c.p.
a. An old bill is a medical expense:
(1) With a date of service or payment date which is within the 24 months immediately prior to the month of application for a prospective or retroactive c.p., or the first month of any subsequent c.p.
EXAMPLE: An application for Medicaid was made on December 10, 2007, for ongoing coverage and for retroactive coverage for September, October, and November, 2007. The unpaid balance of a medical bill that was incurred, or on which any payment was made, on or after December 1, 2005, may be applied to the deductible in either the ongoing or retroactive period.
AND
(2) Which is a current liability, (that is, has not been written off by the provider), including medical bills paid by a loan, as provided in V.
(3) Which has not been applied to a previously met deductible.
(a) If payments are being made on an outstanding medical bill, count the unpaid balance on the first day of the c.p., not the payments.
(b) When an a/r has been authorized because he was hospitalized (see B.), Medicaid may not pay because the deductible balance equaled or exceeded the Medicaid payment. In this case, the unpaid hospital bill may not be applied to the deductible in a subsequent c.p. It was applied to a previously met deductible.
(4) Which has not been denied for payment by a third party due to failure to meet the plan requirements. (See IV.B.3.)
REISSUED 01/01/08 – CHANGE NO. 01-08
(III.A.1)
b. Carry over to a subsequent c.p. the following expenses if they meet the requirements in A.1.a.:
(1) The unused portion of an allowable medical expense in excess of the current deductible,
(2) Any expense applied to a deductible which was not met,
(3) Any expense not previously applied to a deductible, and/or
(4) Any expense which was previously reported, but never verified and applied to a deductible.
c. If there was health insurance, including Medicare and Medicaid, in effect during the prior period, count the unpaid medical bills only after the status of the insurance claim has been verified. Verify that insurance has either paid or denied the claim. Do not count the unpaid bill toward the deductible if the claim was denied for failure to meet the requirements of the plan. An insurance claim must be filed unless it is verified with the insurance company, Medicare or Medicaid that the time limit for filing has expired. (See IV.B)
d. If an old bill could be applied in more than one c.p. explain the options to the client and allow him to choose how to apply the bill. Document the explanation in the case record.
e. Verify the unpaid balance of bills incurred prior to a current c.p. for:
(1) Applications as of the first day of the c.p.
(2) Redeterminations:
(a) Verify the unpaid balance of medical expenses no more than 30 days prior to the date the review is completed.
(b) Apply the unpaid balance on the first day of the c.p.
2. Next, apply charges which are incurred during the certification period in chronological order. This means day by day, in the order in which they are incurred.
a. Charges incurred (paid or unpaid) by a current b.u. member during the c.p. (retroactive or ongoing) for which eligibility is being determined,
And
b. The charge is the responsibility of a current budget unit (b.u.) member,
01/01/01
(III.A.2.b)
And
c. The charge is not subject to payment by insurance or any other third party (see IV.), EXCEPT for :
(1) Hospital bills (see B.) and
(2) Medical bills paid by a public program of the state, county or city government (see IV. D.).
d. Apply to the deductible only the portion of the bill which has not been paid and is the responsibility of the a/r or a current b.u. member when :
(1) Medicare or other insurance or any individual, not the a/r or a current b.u. member, pays a portion or all of the medical bill, or
(2) The medical bill is paid under a fee schedule or reduced rate schedule.
e. Verify expense incurred during the current c.p. by examining receipts, bills, and statements.
3. Apply expenses as follows when there are charges for both covered and non-covered expenses incurred on the same date:
a. Health insurance premiums, including Medicare Part B for applicants, through the month of authorization for Medicaid. (Once the individual is authorized, Medicaid continues to pay the Part B premium until the individual is terminated from Medicaid.)
b. Medical services not covered by Medicaid, such as medically related transportation, non-prescription drugs, etc.
c. Medical services covered by Medicaid. (Refer to MA-3540, Medicaid Covered Services.)
d. When the service is inpatient hospitalization, see B.
4. A “package fee” (other than for inpatient hospital charges) is a charge for a “package” of medical services. A “package fee” is often charged for prenatal and delivery charges. Also, some dental or orthodontic services are charged as a package. Unless the provider can break out the actual fee for each office visit/service in the “package”, the “package fee” can be applied to the Medicaid deductible in one of the following ways:
a. At the point that the entire “package” of services has been completed or provided, apply the total amount of charges for the “package;” OR
(III.A.4.)
b. As payments are made towards the bill, apply the amount of the payment on the date the payment is made. Any unpaid balance on the package may be applied only after completion of the “package” of services.
B. Applying Inpatient Hospital Bills to a Deductible
REVISED 04/01/11 – CHANGE NO. 08-11
(III.B.1.)
f. Follow procedures in B.4. for applying a hospital bill to a deductible when:
(1) The deductible is for an a.u. that does not include the hospitalized person, and
(2) The hospitalized person is in the b.u. of the a.u. that has the deductible, and
(3) The hospitalized person is not in another a.u.
2. Applying Inpatient Hospital or PRTF Charges of a Member of the A.U. to the Deductible for His A.U. (Refer to B.1.e. to determine if B.2. applies.)
a. Inpatient hospital charges of an a/r meet the a.u.’s deductible, regardless of length of stay, amount of charges, or other third party liability, unless the a/r has Medicare Part A coverage.
b. Inpatient PRTF charges of an a/r meet the a.u.’s deductible, regardless of length of stay, ultimate amount of charges, Medicare coverage, or other third party liability. Medicare Part A does not cover PRTF charges.
c. If the a/r has Medicare Part A coverage, and is admitted to a hospital, apply only the amount of the Part A deductible to the a.u.’s Medicaid deductible.
(1) The Part A deductible is due on the date of admission under DRG only when a new Medicare benefit period has begun. (See IV.C.1.) Determine from contact with the a/r or the hospital whether there has been a previous hospitalization in the last 60 days and whether the Part A deductible is applicable to the current hospitalization. Apply the total Medicare Part A deductible toward the Medicaid deductible on the admission date only if the a/r is responsible for paying it.
(2) Apply the Part A deductible amount to the Medicaid deductible on the date of admission, prior to applying other Medicaid covered charges incurred on the same date.
(3) If the Part A deductible meets the a.u.’s Medicaid deductible, authorize the a.u. effective the date of admission. The deductible balance is the amount of the Medicare Part A deductible, or the amount of the Medicaid deductible remaining on the date of admission, whichever is less.
EXAMPLE: The MAF a.u. that includes Ms. Martinez has a Medicaid deductible and Ms. Martinez has Medicare Part A. She enters the hospital on 8/2 and remains until 8/27. The amount of the a.u.’s Medicaid deductible remaining on the date of admission is $459. The Part A deductible of $1,132.00 is applied on 8/2 and meets the Medicaid deductible. The a.u. is authorized effective 8/2 and Ms. Martinez’ Medicaid deductible balance is $459.
REVISED 04/01/11 – CHANGE NO. 08-11
(III.B.2.c.)
If the Part A deductible does not meet the Medicaid deductible, or if the a/r does not owe the Part A deductible because he had a prior hospitalization, continue applying other charges to the deductible, following order in A.2-4. until the deductible is met.
(5) If the Medicaid deductible is met during the hospitalization but after the date of admission, authorize the a.u. effective the date the deductible is met.
(a) If the Medicare Part A deductible is applied to the Medicaid deductible, the deductible balance is always the amount of the Medicare Part A deductible. This is the amount owed by the a/r to the hospital.
EXAMPLE: The MAF a.u. that includes Mr. Chang has a Medicaid deductible, and Mr. Chang has Medicare Part A. He enters the hospital on 6/25 and remains until 6/30. The amount of the a.u.’s Medicaid deductible remaining on the date of admission is $1,155 The Part A deductible of $1,132 is applied on 6/25 leaving $23 remaining. Mr. Chang’s share, after Part B, of the doctor’s charges meets the deductible on 6/26 and the a.u. is authorized on 6/26 with a Medicaid deductible balance of $1,132.
(b) If the Part A deductible was not applied, the deductible balance is always 0. The a/r does not owe for any of the hospital charges.
NOTE: Under DRG, the entire hospital bill will be paid by Medicare and Medicaid, less the deductible balance, if the a/r is authorized on any day during the hospitalization.
(6) If the part A deductible and other expenses incurred while in the hospital do not meet the a/r's deductible, the amount remaining after deducting these amounts is the amount of his deductible left to meet.
EXAMPLE: The MAF a.u. that includes Mr. Riley has a Medicaid deductible, and he has Medicare Part A. He enters the hospital on 7/5 and remains until 7/12. The amount of the a.u.’s Medicaid deductible remaining on the date of admission is $3,450. The Part A deductible of $1,132 is applied on 7/5 leaving $2,318 remaining. Mr. Riley’s out of pocket expenses during his hospital stay total $1,050. After his hospital stay, the a.u. still has $1,268 of the Medicaid deductible left to meet.
d. If the a/r does not have Medicare Part A:
(1) Authorize the a.u. effective the date of admission to the hospital or PRTF.
(2) To determine the deductible balance:
Determine the amount of the deductible remaining on the date of admission.
05/01/02
(III.B.2.d.(2))
(b) Subtract the charges for any medical services not covered by Medicaid, incurred on the day the deductible is met; e.g. health insurance premiums, non-prescription drugs, etc. The remaining amount is the deductible balance to be entered in EIS and reported on the DMA-5020, Notice of Case Status.
Refer to MA-5100, Medicaid Covered Services.
EXAMPLE: The MAF a.u. that includes Mr. Jones is certified February through July. The deductible is $1,836. He is hospitalized on April 12. He does not have Medicare Part A. Prior to April 12 the b.u. had incurred $747 in medical bills to apply to the deductible. Authorize effective April 12 and his deductible balance is $1,089.
e. Insurance
If the a/r has private insurance, be sure that it is on file in EIS so that it will pay before Medicaid. The hospital must bill the insurance company, including the Medicare carrier, before Medicaid pays. Medicaid is always last payor when the a/r has other health insurance coverage.
f. If the recipient met his deductible with hospitalization but has a change in situation that causes an increased deductible, he must meet the additional deductible to be authorized for any remaining portion of the certification period.
3. Applying Inpatient Charges of an A/R to the Deductible of Another A.U. (Refer to III.B.1.e. to determine if III.B.3. applies.)
When an a/r who is also a financially responsible parent or spouse for his child/spouse in another a.u. with a deductible, and the a/r has an inpatient hospitalization during the current c.p., do not assume the a/r’s hospital bill will meet the deductible for his child/spouse’s a.u. How the bill is applied to the other a.u. depends upon whether the hospitalized a/r has Medicare Part A (Not applicable to PRTF admission, which is not covered by Medicare.) and whether the hospitalization meets his own deductible.
a. Follow instructions in B.2 to apply inpatient hospital or PRTF charges to the a/r’s own deductible (or MA-2360, Medicaid Deductible, if he is an MAABD a/r).
b. If the hospitalized a/r does not have Medicare Part A, the hospitalization meets his Medicaid deductible on the day of admission. Treat his deductible balance on the date of admission as a medical bill to apply to the deductible for the a.u. of his child/spouse.
(III.B.3.b.)
|
|
|
|
Father’s budget:
|
Child’s budget:
|
$880
|
Income
|
$400
|
Child’s income
|
-20
|
|
+ $880
|
Father’s income
|
$860
|
|
1,280
|
|
- 242
|
|
- 317
|
|
$618
|
|
963
|
|
x 6
|
|
x 6
|
|
$3,708
|
Deductible
|
5,778
|
|
The father is hospitalized. Assuming he had no other medical expenses, he would be authorized for MAD on the date of hospital admission. His deductible balance is $3,708. Apply this amount to the child’s deductible.
$5,778
|
Child’s deductible
|
-$3,708
|
Father’s deductible balance
|
2,070
|
Child’s remaining deductible
|
c. If the hospitalized a/r has Medicare Part A, only the Part A deductible may be applied to his Medicaid deductible. Apply the a/r’s hospitalization charges to the deductible of the a.u. of his child/spouse as follows:
REISSUED 11/01/11 – CHANGE NO. 15-11
(III.B.3.c.)
(1) If the Part A deductible meets his Medicaid deductible during the hospitalization, treat his deductible balance on the day of authorization as a medical charge to apply to the Medicaid deductible for the a.u. of his child/spouse.
(2) If the Part A deductible does not meet his Medicaid deductible on the day of admission, apply the Part A deductible amount to the deductible for the a.u. of his child/spouse on the date of admission. Continue applying charges incurred by the hospitalized a/r to his deductible and to the deductible of his child/spouse.
(3) Once the hospitalized a/r’s deductible is met, treat his deductible balance on the day of authorization as a medical bill to apply to the deductible of the a.u. of his child/spouse.
EXAMPLE 2: Same situation, except father has Medicare Part A. The Part A deductible of $1,132 is applied to his Medicaid deductible on January 4, the date of admission, leaving $2,640 still to be met. The $1,132 is also applied to the child’s deductible. Other charges are incurred on January 5 and January 6 totalling $2,612. The father incurs $400 on January 7 and he meets his deductible on January 7, while still in the hospital. The deductible balance reported in EIS and to the hospital is the Medicare Part A deductible ($1,132). Refer to B.2.c.(3). The amount of his deductible remaining on January 7 ($28) is applied to his child’s deductible.
|
|
|
|
Father’s deductible
|
Child’s deductible
|
$3,772
|
|
$5,842
|
|
- 1,132
|
Part A deductible
|
- 1,132
|
Part A deductible
|
2,640
|
Remaining
|
4,710
|
Remaining
|
- 2,612
|
Additional charges
|
-2,612
|
Additional charges
|
28
|
Remaining
|
2,098
|
Remaining
|
- 400
|
1/7 charges
|
- 28
|
Father’s debt balance
|
|
|
|
$2,070
|
Remaining
|
REVISED 11/01/11 – CHANGE NO. 15-11
(III.B.)
4. Applying Inpatient Charges of a Budget Unit (B.U.) Member Who Is Not an A/R (Refer to B.1.f. to determine if this applies.)
a. Apply inpatient bills of a b.u. member who is not an a/r on a daily basis as they are incurred.
b. If the inpatient bills were incurred prior to the certification period, follow instructions in A.1.
C. Documentation and Verification
1. Document charges applied to the current Medicaid deductible on DMA-5036, Record of Medical Expenses Applied to the Deductible. Include date of service, patient name, provider name, and amount for each charge. If the a/r is not responsible for the entire charge, include the amount for which he is responsible. If medical bills are for dates of service prior to the current c.p., verify the a/r’s current liability.
a. Document the following for all medical bills, except inpatient hospital bills of an individual incurred during the current c.p.:
(1) Date of service
(2) Type of service
(3) Amount of total charges
b. For inpatient hospital or PRTF admissions of the a/r in the current c.p., verify date of admission and confirm that the stay was considered inpatient.
c. In addition to items in a. and b., above for medical bills, including hospital bills, incurred prior to the current c.p. document the following:
(1) Status of bill (whether paid or unpaid). If paid by a loan, refer to V. for procedures regarding loans to pay medical expenses.
(2) Amount applied to deductible
(3) Amount of unpaid balance
(4) Date of verification of the unpaid balance
2. Sources of Verification
a. Verify medical expenses by seeing the bills and statement in the client's possession
or
REVISED 11/01/11 – CHANGE NO. 15-11
(III.C.2)
b. Complete the DMA-5037, Medical Provider Verification Form, for each identified medical provider. The a/r may assume responsibility for obtaining provider verification, but IMC must assist if a/r requests assistance. The a/r may also meet this requirement by presenting a current bill that includes:
(1) Date of service
(2) Type of service
(3) Amount of total charges
(4) Status of bill (whether paid or unpaid), and
(5) Date of last payment on account
(6) Amount of last payment, and
(7) Amount of unpaid balance
D. Authorization and Reporting of Deductible Balance
1. Authorize on the date the amount of the medical charges equals the amount of the deductible, provided all other factors of eligibility are met. If a hospital stay is involved, see B.
2. If an additional medical bill is presented after a case has been authorized, determine whether it will result in an earlier authorization.
a. Ongoing Case
(1) If the bill is presented during the c.p., and the deductible is met on an earlier date, authorize the earlier day(s) according to instructions in the EIS USERS MANUAL.
(2) If the bill is presented after the c.p., apply in the subsequent period(s), if still unpaid. (See A.1.)
(3) Send adequate notice, to notify the individual of the action taken.
b. Terminated Case
(1) If the bill is presented within 12 months of the termination date, and the deductible is met on an earlier date, authorize the earlier day(s) according to instructions in the EIS USERS MANUAL.
REISSUED 11/01/11 – CHANGE NO. 15-11
(III.D.2.b.)
(2) If an override of the time limit for filing claims is needed, refer to MA-3530, Corrective Actions and Responsibility for Errors, for procedures.
(3) Send adequate notice to notify the individual of the action taken.
3. If medical bills sufficient to meet the deductible are presented on an ongoing case that was certified but not authorized,
a. Determine the date the deductible was met; and
b. Authorize according to instructions in the EIS USERS MANUAL.
4. If a change in situation results in a new deductible, apply in the first month of the new deductible period any unpaid bills not previously counted and which meet the requirements in A. 1.
5. Determining the Deductible Balance
a. The deductible balance is the total amount of the deductible remaining to be met on the date the case is authorized. This is the amount entered in EIS.
b. If the deductible is met during inpatient hospitalization or PRTF stay, the deductible balance is the amount the a/r must pay. It is reported to the hospital or PRTF as the liability on the DMA-5020, Notice of Case Status, and must be the same as the deductible balance entered in EIS. Follow the policy in B. to determine the deductible balance.
a. Authorize the case when documented medical expenses equal the amount of the deductible. Enter in EIS the deductible balance amount on the date of authorization.
(1) If the deductible is met due to the a/r’s inpatient hospitalization or PRTF stay, enter the same deductible balance into the deductible balance field in EIS that is reported to the hospital or PRTF on the DMA-5020, Notice of Case Status. (Refer to B.1. and 2.)
(2) If an inpatient hospitalization or PRTF admission of the a/r is not involved, report the total deductible balance in EIS as the amount of deductible met on the date of authorization.
b. Do not report a deductible balance in EIS when the deductible was met using old bills on the first day of the c.p.
REVISED 11/01/11 – CHANGE NO. 15-11
(III.D.)
