Section He-W 878.01 - In and Out Medically Needy Medical Assistance(a) The department shall provide in and out medically needy medical assistance in accordance with 42 CFR 435.301 to individuals: (1) Who meet all categorical, technical, and resource requirements for medically needy medical assistance;(2) Whose income exceeds the protected income level for medically needy medical assistance; and(3) Whose incurred medical expenses and obligated prior medical debts, including non-covered medical services incurred in an eligible month, which have not been used to offset a prior spenddown, are at least equal to the difference between their income and the protected income level for medically needy medical assistance.(b) The department shall recognize the following incurred medical expenses, and currently unpaid, obligated prior medical debts toward the in and out spenddown: (1) Medical insurance premiums, deductibles or co-insurance charges;(2) Necessary medical or remedial care that would be covered by medical assistance including when allowable incurred amounts exceed service limits described in He-W 530.03; and(3) Necessary medical or remedial care that is recognized by state law but not covered by medical assistance described in He-W 530.06(a) .(c) Incurred current medical expenses and obligated prior medical debts of individuals of a family, as defined in He-W 601.04(c) , or family members, as defined in He-W 601.04(f) , who reside in the same living unit as the client or for whom the client is liable, shall be used to satisfy the spenddown amount.(d) Prior medical debts shall not be prioritized or required to be used in sequential order and shall be prorated at the client's option over several months if the total amount of the debt exceeds the spenddown amount.(e) The department shall apply incurred, unpaid medical expenses and currently obligated medical debts toward the spenddown in the following order: (1) Unpaid prior medical debts and uncovered medical expenses shall be applied on the first day of the month of the in and out period;(2) Medical insurance premiums due during the month shall be applied on the first day of the month in which they are due; and(3) Current medical expenses which are or would be covered by medical assistance shall be applied chronologically after uncovered expenses and may be applied to the following month if they remain unpaid on the first day of the following month and have not already been applied toward a spenddown.(f) A medical expense or prorated expense described in (d) above shall be used only once to offset the spenddown.(g) The client may choose either a one or 6 month spenddown period when the department determines eligibility for in and out medically needy medical assistance, subject to the following provisions: (1) An application for in and out medically needy medical assistance shall be valid only for a maximum of 6 consecutive months;(2) The client shall be given the spenddown amounts for both a one and 6 month spenddown period on their notice of decision;(3) The client shall not be required to choose either a one or 6 month spenddown until they submit verification of medical expenses to the department and the case meets all eligibility criteria; and(4) Once the client has elected a one month spenddown period and the case has been opened, they shall not have a 6 month spenddown period unless they reapply for assistance.(h) When the client has chosen a one month spenddown period, the amount by which monthly income exceeds the protected income level as defined in He-W 601.06(s) shall be the client's spenddown amount, and the spenddown amount shall be computed separately for each month.(i) When the client has chosen a 6 month spenddown period, the spenddown amount shall be equal to 6 times the difference between monthly income and the protected income level.(j) Reported or known changes in case circumstances such as, but not limited to, changes in income, household composition, and increases in the protected income level shall affect the one month spenddown amount as follows:(1) Before a case is opened for a one month period, changes in case circumstances which affect the spenddown amount shall be used to determine eligibility; and(2) Once a case is opened for a one month period, changes in case circumstances shall not affect the spenddown amount.(k) Reported or known changes in case circumstances, such as but not limited to changes in income, household composition, and increases in the protected income level which affect the 6 month spenddown amount shall be used to determine eligibility as follows:(1) Before a case is opened for a 6 month period, all known changes affecting that 6 month period shall be taken into account prior to opening, and the department shall calculate the changes for the affected months and establish a new spenddown for the 6 months;(2) Once a case has been opened for a 6 month spenddown period and has a change that would increase the spenddown amount, the department shall take the change into account and take action to review eligibility by computing a new spenddown amount and, if the case is ineligible, terminate in and out medically needy medical assistance; and(3) Once a case has been opened for a 6 month spenddown period and has a change that would decrease the spenddown amount, the department shall determine if the decrease affects the original date of eligibility.(l) Eligibility for in and out medically needy medical assistance shall begin on the day of the month in which incurred medical costs equal or exceed the amount of the spenddown.(m) The client shall notify the department in person, in writing, or by telephone when he or she has incurred medical costs which equal or exceed the amount of the spenddown.N.H. Admin. Code § He-W 878.01
Amended byVolume XXXV Number 01, Filed January 8, 2015, Proposed by #10743, Effective 12/12/2014, Expires12/12/2024.