Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Part 10 - MEDICALLY NEEDY ELIGIBILITY CRITERIA › Section 144-332-10-6 - NON-APPLICABLE MEDICAL COSTS

Current through 2024-29, July 17, 2024
The following types of medical bills cannot be considered
					 toward a deductible:
I. Medical costs
				  incurred and paid prior to the eligibility period.
II. Portions of medical costs applied toward
				  a previous deductible, if the deductible is met.
III. Portions of medical costs paid by
				  insurance, including Medicare adjustments.
IV. Medical costs paid by individuals or
				  groups outside the assistance unit for which the individual has no obligation
				  to repay. The exception is medical costs paid with all state or local funds
				  such as General Assistance, DEL and some payments by Vocational Rehabilitation
				  (VR).
V. Medical costs incurred by
				  individuals who are not members of the assistance unit and whose income and
				  assets are not used in determining eligibility.
VI. Payments on old medical bills incurred
				  prior to the eligibility period.
VII. Medical costs incurred during a penalty
				  period.
VIII. Unpaid costs of care
				  to a medical institution or waiver agency during periods of eligibility.
Example
This example shows how medical expenses are applied to a
					 deductible and the order in which they must be applied.
An individual, age 22, determined disabled in April,
					 submits the following bills to meet a deductible of $3820 for April through
					 September.
Determine that there are no changes to the deductible
					 amount and that all of the bills submitted can be used toward the current
					 remaining deductible:
Total Deductible
:
$3820.00
I.
Medical Insurance premium
($79.05
								monthly X 6)
Remaining deductible
- $ 474.30
______________
$3345.70
II.
Items not covered by Medicaid
Eyeglasses (purchased 4/12)
Remaining deductible
- $ 125.00
_____________
$3220.70
III.
Old unpaid medical bills
Doctor's statement shows an outstanding balance as
								of 3/31 of $650.00
Remaining deductible
- $ 650.00
______________
$2570.70
IV.
Medicaid coverable costs paid or unpaid
								incurredduring the eligibility period
The hospital bill for 4/3 through 4/6 ($3500) was
								not itemized for insurance payments ($1200). To determine the daily portion of
								the hospital bill the client is responsible for - divide the total insurance
								payment by the total hospital bill to the 4th decimal place ($1200 ÷
								$3500 =.3428).
4/3 Charges
Multiply 4/3 hospital bill by.3428 ($1500 x.3428 =
								$514.20)
Subtract the result from the 4/3 hospital
								bill
($1500 - $514.20 = $985.80)
4/3 hospital charge used against the
								deductible
Remaining deductible
- $ 985.80
________
$1584.90
4/4 Charges
Multiply 4/4 hospital bill by.3428 ($1000 x.3428 =
								$342.80)
Subtract the result from the 4/4 hospital
								bill
($1000 - $342.80 = $657.20)
Physician's bill after insurance
Prescription
+ $
								46.25
Total charges for 4/4
Remaining deductible
$ 657.20
+ $ 65.00
_______
- $ 768.45
$ 816.45
4/5 Charges
Multiply 4/5 hospital bill by.3428 ($900 x.3428 =
								$308.52)
Subtract the result from the 4/5 hospital
								bill
($1000 - 308.52 = $691.48)
Physician's bill after insurance
Radiology services after insurance
Total charges for 4/5
$ 691.48
+ $ 200.00
+ $ 400.00
__________
$1291.48
The charges for 4/5 are greater than the remaining
					 deductible of $816.45.
The applicant met the deductible on 4/5. The first full day
					 of coverage is 4/6.
The applicant is responsible for the remaining deductible
					 of $816.45 and there are a number of bills on 4/5.
To determine the applicant's share for each provider for
					 bills incurred on 4/5:
I. Divide
				  remaining deductible by total charges for 4/5 to the 4th decimal place.
($816.45 ÷ $1291.48 =.6322)
II. Multiply each provider's bill by.6322.
				  This is the amount the applicant is responsible for.
Hospital $691.48 x. 6322 = $ 437.13
Physician $200.00 x.6322 = $ 126.44
Radiology $400.00 x.6322 = $ 252.88
Applicant responsibility for 4/5 $
					 816.45