N.J. Admin. Code § 10:70-6.2

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:70-6.2 - Allowable incurred medical expenses

(a) Allowable incurred medical expenses which may be applied against spend-down liability are those which are:

1. Incurred by a member of the budget unit and for which a member of the budget unit has an express obligation for payment;

2. For necessary medical or remedial services recognized under state law, provided, prescribed, or recommended by a qualified and appropriately licensed medical practitioner; and

3. Submitted with sufficiently detailed information and documentation to determine the allowableness of the expense. Minimum necessary information includes: the date of the service, name of the provider, the nature of the service, the name of the individual to whom the service was provided, and the total amount of the bill, as well as the remaining balance outstanding.

(b) Medical expenses which have been paid in full prior to the retroactive budget period, shall not be applied against spend-down liability. However, medical expenses paid by a member of the budget unit during an eligibility period may be used in meeting spend-down liability so long as the expense met the criteria specified in (a) above.

(c) The county board of social services shall refer the submission of expenses for questionable medical services to designated staff of the Division of Medical Assistance and Health Services for a determination of allowableness.

(d) To the extent that payment of any bill for medical service is the responsibility of a third party (for example, a health insurer), the expense shall not be applied against spend-down liability. An exception would be made for any medical expense paid by a State or territory, or a subdivision of a State or territory (except for a Medicaid program), if the program is financed by a State or territory.

(e) Any bill for medical services rendered more than six months prior to the bill's submission to the county board of social services for application against spend-down liability must be accompanied by a statement from the provider that the expense remains an express obligation of a member of the budget unit and has not been forgiven by the provider or otherwise determined uncollectible.

N.J. Admin. Code § 10:70-6.2

Amended by R.1991 d.331, effective 7/1/1991.
See: 23 N.J.R. 964(a), 23 N.J.R. 2042(a).
Modification of spend-down requirement at (d) based on federal Department of Health and Human Services, (HCFA) in the State Medicaid Manual, Part 3--Eligibility, Transmittal 48, Nov. 1990.
Amended by R.2006 d.364, effective 10/16/2006.
See: 38 N.J.R. 2368(a), 38 N.J.R. 4480(c).
In (c) and (e), substituted "board of social services" for "welfare agency".