10- 144 C.M.R. ch. 332, § 10-6

Current through 2024-51, December 18, 2024

Section 144-332-10-6 - NON-APPLICABLE MEDICAL COSTS

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

10- 144 C.M.R. ch. 332, § 10-6