10- 144 C.M.R. ch. 332, § 10-4
Individuals who are ineligible under Categorically Needy and whose income is above the appropriate Protected Income Level (PIL) are not eligible for Medicaid until they meet a deductible. The deductible is met by applying incurred costs for necessary medical services to the deductible amount.
The result is the deductible amount the individual or family must meet by applying incurred medical costs before coverage can begin.
The deductible amount must be reviewed prior to opening coverage. When changes occur that impact Medically Needy eligibility (e.g. changes in income or household composition), eligibility is redetermined and the deductible amount is recalculated. If the Medically Needy period ends or the deductible amount increases, the Eligibility Specialist must give the individual timely and adequate notice of the change. (See Part 2 Section 15. )
Bills or other acceptable verification of incurred medical expenses must be submitted within one year of the application date to be applied to the deductible.
To be counted toward the deductible, a bill must be for medical services that are medically necessary and for which the individual is legally liable. The cost of necessary medical services for individuals in the assistance unit and for individuals whose income or assets are or would be used in determining eligibility may be applied against the deductible.
For individuals who are included in more than one assistance unit, the cost of necessary medical services can be applied toward each deductible.
When an individual or family has sufficient costs to meet the deductible, but an accurate start date cannot be determined due to missing bills or pending insurance payments, eligibility begins for the first full month of eligibility. Eligibility is back dated when all information is provided.
The deductible may be met by using medical costs that were incurred prior to the deductible period. When the deductible is met in this manner, the individual is eligible for MaineCare effective the first day of the eligibility period. Otherwise, coverage will begin when the deductible is met.
The medical expenses used to meet the deductible are the individual's obligation and cannot be billed to Medicaid.
On the day the deductible is met, the individual may be partially responsible for the bills incurred on that date. When this occurs, the Department will inform the provider in writing that the individual is eligible for Medicaid on the day the deductible was met. The notice will also include the amount of the bill the individual is responsible for paying.
If bills from multiple providers were applied on the date the deductible was met, the individual's responsibility must be distributed equally to each provider. To determine the individual's responsibility for each provider:
If medical bills that could have been used to meet the deductible are received for a period prior to the date the deductible was met, but between the first date of eligibility and the start of the Medically Needy period, a notice will be sent to the client and provider showing a zero responsibility for the client. These bills will be covered if they are submitted within one year of the date of the eligibility decision.
10- 144 C.M.R. ch. 332, § 10-4