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 8 - Post-Eligibility Treatment of Income (PETI) › Section 210-RICR-50-00-8.7 - Health Expenses

Current through June 14, 2024
A. Health care and
				  insurance. Additional amounts of the income of a Medicaid LTSS beneficiary may
				  be protected to cover certain medical/health costs incurred by the beneficiary
				  or financially responsible relatives, such as spouse, sibling, or adult child.
1. Health Coverage Costs - Health care
				  premiums, co-payments and deductibles incurred by the Medicaid LTSS beneficiary
				  that are not subject to payment by Medicaid or a third (3rd) party may be
				  deducted from income. This includes the beneficiary's costs for Medicare,
				  including Medicare Advantage and Part D plans, supplemental health insurance
				  for dental and/or vision and long-term care insurance policy premiums. Only the
				  portion of these costs that is for the Medicaid beneficiary are
				  allowed.
2. Allowable Medical
				  Expenses - Unpaid past expenses for medically necessary services may be
				  deducted from available income in certain circumstances. For such expenses to
				  reduce available income for beneficiary liability determination purposes, they
				  must meet all the criteria to be considered allowable and exclude any costs of
				  care already used to meet the beneficiary's spenddown. A medical expense must
				  be allowable under this section to be deducted in the LTSS income calculation.
				  An allowable expense must meet the following conditions:
a. Medically necessary. The expense must be
				  medically necessary. A necessary medical expense is an expense rendered - for
				  any of these situations:
(1) In response to a
				  life-threatening condition or pain;
(2) Treat an injury, illness or
				  infection;
(3) Achieve a level of
				  physical or mental function consistent with prevailing community standards for
				  the diagnosis or condition;
(4)
				  Provide care for a mother and child through the maternity period;
(5) Prevent the onset of a serious disease or
				  illness;
(6) To treat a condition
				  that could result in physical or behavioral health impairment; or
(7) 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.
b.
				  Non-Medicaid Service. The expense must not be covered by Medicaid. An expense
				  cannot be deducted if it is a Medicaid-covered service and is incurred in a
				  month in which eligibility may exist, including the month of application and
				  the retroactive eligibility period. Exceptions are granted for Medicaid covered
				  services only if the health costs were incurred for a medically necessary
				  service provided prior to the retroactive eligibility period and are a legally
				  binding debt obligation or attachment or lien as indicated in §
												8.6(A)(2)(b)
				    of this Part. In addition:
(1) An expense
				  incurred in a month for which eligibility is approved is presumed to be a
				  Medicaid covered service unless the applicant provides documentation that it is
				  not.
(2) When an applicant for LTSS
				  is receiving a service or set of services Medicaid pays for in a daily or
				  bundled rate, the items and services included in that rate are not separate
				  allowable expenses whether provided in an institution, such as an NF or
				  hospital, or home and community-based setting, such as a DD group home,
				  assisted living residence, etc.
c. No Third Party Payment. 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 benefits 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; Workers' Compensation.
d. Allowed Expense Period. The expense must
				  be incurred during a month in which the applicant/beneficiary is receiving
				  Medicaid-funded LTSS or the retroactive period unless the exception for legally
				  binding debt or attachments apply. The first (1st) day of the month an
				  application for LTSS is filed, or a request for review of an expense is
				  submitted is the start date for determining whether an expense qualifies,
				  regardless of whether retroactive coverage is requested or approved.
(1) An expense incurred during the three (3)
				  month retro-period must be unpaid as of the date the agency received the
				  request, unless it was incurred in a month that Medicaid LTSS coverage was
				  active.
(2) An expense incurred
				  while Medicaid LTSS is active may be paid or unpaid.
3. Limits - If all of the above
				  conditions apply, the expense may still not be allowed in certain
				  circumstances:
a. Expense in penalty period.
				  An expense cannot be deducted for an LTSS service incurred during a penalty
				  period in due to an uncompensated transfer. However, non-LTSS expenses, such as
				  primary, acute or subacute care services incurred during a period of
				  ineligibility, may be an allowable expense if all other conditions are
				  met.
b. Used for other reductions.
				  The expense must not have been treated as or paid:
(1) To reduce excess resources - an expense
				  paid by an applicant to meet resource eligibility limits cannot be deducted in
				  the income calculation.
(2) As an
				  income exclusion or deduction - an expense previously used as a deduction in
				  the income calculation cannot be used under this section.
4. Charges Not Allowed - Under
				  current Federal Regulations, the following services are not allowable expense
				  deductions when provided to a Medicaid applicant:
a. Personal Items. Items such as shampoo,
				  toothpaste or dental floss;
b.
				  Elective or Expanded Services. Optional or elective features to services and
				  supports that are not medically necessary, such as a motorized wheelchair,
				  prescription sunglasses, elective treatments or procedures for non-medical
				  purposes;
c. Provider travel. A
				  charge for a provider to travel to an applicant's residence when no medical
				  service is provided.
5.
				  Deduction Timeline - Allowable expenses are deducted in the LTSS income
				  calculation for the month in which the expense is incurred. Expenses that were
				  incurred in the three (3) months prior to the month the request for payment of
				  LTSS services is submitted can be deducted beginning in the first month of
				  eligibility.
6. Excess Carryover -
				  The excess amount of an allowable expense can be carried forward and used as a
				  deduction in future months when the amount of the expenses combined exceeds the
				  amount of income remaining after all other deductions.