Section 210-RICR-50-00-2.6 - LTSS Medically Needy Allowable ExpensesA. The health expenses of the LTSS beneficiary and spouse and dependents, if applicable, may be used to obtain or retain MN eligibility if they qualify as allowable under this Part. The expenses may be paid or incurred and not paid depending on the deduction sequence, the age of the health bills, and whether the expenses are predictable and/or used for other eligibility purposes such as reducing resources or beneficiary liability for the cost of care.B. For an incurred health expense to qualify as allowable for a LTSS MN spenddown, the following apply: 1. No third-party liability - 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 policies 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; or Workers' Compensation. Expenses incurred by the spouse or a financially responsible relative are NOT treated as a third (3rd) party liability if such expenses are allowable and the services are provided to the applicant or beneficiary.2. Medically necessary - The expense must be medically necessary. A necessary medical expense is an expense rendered for any of these situations: a. In response to a life-threatening condition or pain;b. Treat an injury, illness or infection;c. Achieve a level of physical or mental function consistent with prevailing community standards for the diagnosis or condition;d. Provide care for a mother and child through the maternity period;e. Prevent the onset of a serious disease or illness;f. To treat a condition that could result in physical or behavioral health impairment; or g. 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.3. Single use - The total amount of a health expense may not be used more than once to meet an eligibility or spenddown requirement. However, if only a portion of a health expense is used to meet the spenddown requirement in a budget period, the portion of the allowable expense that remains is a current liability and may be applied toward a spenddown requirement in a future budget period.4. Retroactive coverage - Allowable expenses incurred in the three (3) months prior to the date of application may be used to grant Medicaid MN coverage if all other eligibility criteria were met during the retroactive period. If not used to seek eligibility for this period, expenses incurred that are not used for this purpose may be applied in accordance with §2.6.1(B) of this Part below.5. Deduction timeframes - Health costs may qualify as allowable expenses when incurred: a. During the current budget period, whether paid or unpaid;b. Before the current budget period and paid in the current period;c. Before the current period, remain unpaid, and continuing has been established; ord. Paid during the current budget period by a government entity or program that does not receive Medicaid funding.6. Loans - Health expenses incurred before or during the budget period and paid for by a bona fide loan may be deducted if the expense has not been previously used to meet a spenddown requirement and the applicant or beneficiary or a financially responsible person establishes continuing liability for the loan. To be an allowable expense, all or part of the principal amount of the loan must remain outstanding at some point during the budget period. For these purposes, a bona fide loan means an obligation, documented from its outset by a written contract and a specified repayment schedule. Only the amount of the principal outstanding during the budget period, including payments made on the principal during that period, may be deducted.2.6.1Types of Allowable Expenses and Sequence of DeductionsA. The types of health and remedial expenses that qualify as "allowable" for the purposes of a MN spenddown are the same for both community Medicaid and LTSS. Such expenses include, but are not limited to: physician/health care provider visits; health insurance premiums, co-pays, co-insurance, and deductibles; dental and vision care; chiropractic and podiatric visits; prescription medications; tests and X-rays; skilled nursing and subacute care if not otherwise covered; home nursing care, such as personal care attendants, private duty nursing and home health aides; audiologists and hearing aids; dentures; durable medical equipment such as wheelchairs and protective shields; therapy, such as speech, physical, or occupational therapy; transportation for medical care, such as car, taxi, bus or ambulance; and LTSS expenses at home or in a health institution at the State Medicaid reimbursement rate.B. An expense is allowable for the Medicaid LTSS spenddown if it is for health insurance costs or specific types of Medicaid non-covered and covered services. The scope, amount and duration of the service determines whether it qualifies as an allowable expense as a Medicaid covered or non-covered service and, therefore, the order in which it is deducted from excess income. The sequence of deductions for allowable expenses is as follows:1. Health insurance expenses - The costs for maintaining insurance coverage for health care services and supports for both the person seeking coverage and any dependents. This category includes, premiums, co-pays, co-insurance and deductibles including for Medicare and commercial plans. Premiums for optional supplemental plans are not allowable expenses.2. Non-Medicaid expenses - These are expenses incurred for health care and remedial services that are recognized under State law but are not covered under the Medicaid State Plan or the State's Section 1115 demonstration waiver, such as home stabilization services and non-medical transportation.3. Excess Medicaid expenses - Includes expenses incurred for Medicaid covered services that exceed limitations on amount, duration, or scope established in the State Plan or Section 1115 demonstration waiver. Expenses allowed in this category must be medically necessary and may include both the costs incurred for an expanded service (such as dentures, in-patient behavioral health care for an extended period, contact lenses or a second pair of prescription reading glasses) and associated ancillary health costs (x-rays, needs assessments, lab tests, office visits and the like).4. Covered Medicaid expenses - These are incurred expenses that do not exceed limitations on amount, duration, or scope allowed under current Federal authorities. They are deducted in chronological order based on the date of service beginning with the oldest expense.a. An expense incurred in a month for which MN eligibility is approved is presumed to be a Medicaid covered expense unless documentation is provided to the State that it is not a covered service.b. 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.5. Health institution expenses - Under the existing Medicaid State Plan, Rhode Island took the option under 42 C.F.R. § 435.831(3)(g)(1) to allow LTSS expenses incurred for both HCBS and health institutional care to be deducted from excess income. In accordance with the applicable Federal requirements therein, the maximum amount allowed is the State monthly Medicaid reimbursement rate projected to the end of the budget period when paid or incurred.210 R.I. Code R. 210-RICR-50-00-2.6
Amended effective 2/23/2021
Amended effective 12/28/2023