Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 00 - Long-Term Services › Part 2 - Long-term Services and Supports (LTSS) Medically Needy Eligibility Pathway › Section 210-RICR-50-00-2.6 - LTSS Medically Needy Allowable Expenses

Current through June 14, 2024
A. The
				  health expenses of the LTSS beneficiary and spouse and dependents, if
				  applicable, may be used to obtain or retain MN eligibility if they qualify as
				  allowable under this Part. The expenses may be paid or incurred and not paid
				  depending on the deduction sequence, the age of the health bills, and whether
				  the expenses are predictable and/or used for other eligibility purposes such as
				  reducing resources or beneficiary liability for the cost of care.
B. For an incurred health expense to qualify
				  as allowable for a LTSS MN spenddown, the following apply:
1. No third-party liability - An allowable
				  expense must not be eligible for payment by a third (3rd) party. For these
				  purposes, a third (3rd) party could be individuals, entities or policies that
				  are, or may be, liable to pay the expense including, but not limited to: other
				  health care coverage, such as coverage through Medicare, private or group
				  health insurance, long-term care insurance or through the Veterans
				  Administration (VA) health system; automobile insurance; court judgments or
				  settlements; or Workers' Compensation. Expenses incurred by the spouse or a
				  financially responsible relative are NOT treated as a third (3rd) party
				  liability if such expenses are allowable and the services are provided to the
				  applicant or beneficiary.
2.
				  Medically necessary - The expense must be medically necessary. A necessary
				  medical expense is an expense rendered for any of these situations:
a. In response to a life-threatening
				  condition or pain;
b. Treat an
				  injury, illness or infection;
c.
				  Achieve a level of physical or mental function consistent with prevailing
				  community standards for the diagnosis or condition;
d. Provide care for a mother and child
				  through the maternity period;
e.
				  Prevent the onset of a serious disease or illness;
f. To treat a condition that could result in
				  physical or behavioral health impairment; or
g. When such services are provided or ordered by a licensed health
				  care professional or provider they are presumed to be medically necessary. In
				  instances when such services are provided by some other person or entity,
				  documentation of medical necessity may be required.
3. Single use - The total amount of a health
				  expense may not be used more than once to meet an eligibility or spenddown
				  requirement. However, if only a portion of a health expense is used to meet the
				  spenddown requirement in a budget period, the portion of the allowable expense
				  that remains is a current liability and may be applied toward a spenddown
				  requirement in a future budget period.
4. Retroactive coverage - Allowable expenses
				  incurred in the three (3) months prior to the date of application may be used
				  to grant Medicaid MN coverage if all other eligibility criteria were met during
				  the retroactive period. If not used to seek eligibility for this period,
				  expenses incurred that are not used for this purpose may be applied in
				  accordance with §2.6.1(B)   of this Part below.
5. Deduction timeframes - Health costs may
				  qualify as allowable expenses when incurred:
a. During the current budget period, whether
				  paid or unpaid;
b. Before the
				  current budget period and paid in the current period;
c. Before the current period, remain unpaid,
				  and continuing has been established; or
d. Paid during the current budget period by a
				  government entity or program that does not receive Medicaid funding.
6. Loans - Health expenses
				  incurred before or during the budget period and paid for by a
bona
				  fide
loan may be deducted if the expense has not been previously used
				  to meet a spenddown requirement and the applicant or beneficiary or a
				  financially responsible person establishes continuing liability for the loan.
				  To be an allowable expense, all or part of the principal amount of the loan
				  must remain outstanding at some point during the budget period. For these
				  purposes, a
bona fide
loan means an obligation, documented
				  from its outset by a written contract and a specified repayment schedule. Only
				  the amount of the principal outstanding during the budget period, including
				  payments made on the principal during that period, may be deducted.