Section 210-RICR-50-00-8.7 - Health ExpensesA. Health care and insurance. Additional amounts of the income of a Medicaid LTSS beneficiary may be protected to cover certain medical/health costs incurred by the beneficiary or financially responsible relatives, such as spouse, sibling, or adult child. 1. Health Coverage Costs - Health care premiums, co-payments and deductibles incurred by the Medicaid LTSS beneficiary that are not subject to payment by Medicaid or a third (3rd) party may be deducted from income. This includes the beneficiary's costs for Medicare, including Medicare Advantage and Part D plans, supplemental health insurance for dental and/or vision and long-term care insurance policy premiums. Only the portion of these costs that is for the Medicaid beneficiary are allowed.2. Allowable Medical Expenses - Unpaid past expenses for medically necessary services may be deducted from available income in certain circumstances. For such expenses to reduce available income for beneficiary liability determination purposes, they must meet all the criteria to be considered allowable and exclude any costs of care already used to meet the beneficiary's spenddown. A medical expense must be allowable under this section to be deducted in the LTSS income calculation. An allowable expense must meet the following conditions: a. Medically necessary. The expense must be medically necessary. A necessary medical expense is an expense rendered - for any of these situations:(1) In response to a life-threatening condition or pain;(2) Treat an injury, illness or infection;(3) Achieve a level of physical or mental function consistent with prevailing community standards for the diagnosis or condition;(4) Provide care for a mother and child through the maternity period;(5) Prevent the onset of a serious disease or illness;(6) To treat a condition that could result in physical or behavioral health impairment; or(7) 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.b. Non-Medicaid Service. The expense must not be covered by Medicaid. An expense cannot be deducted if it is a Medicaid-covered service and is incurred in a month in which eligibility may exist, including the month of application and the retroactive eligibility period. Exceptions are granted for Medicaid covered services only if the health costs were incurred for a medically necessary service provided prior to the retroactive eligibility period and are a legally binding debt obligation or attachment or lien as indicated in § 8.6(A)(2)(b) of this Part. In addition: (1) An expense incurred in a month for which eligibility is approved is presumed to be a Medicaid covered service unless the applicant provides documentation that it is not.(2) 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.c. No Third Party Payment. 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 benefits 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; Workers' Compensation.d. Allowed Expense Period. The expense must be incurred during a month in which the applicant/beneficiary is receiving Medicaid-funded LTSS or the retroactive period unless the exception for legally binding debt or attachments apply. The first (1st) day of the month an application for LTSS is filed, or a request for review of an expense is submitted is the start date for determining whether an expense qualifies, regardless of whether retroactive coverage is requested or approved. (1) An expense incurred during the three (3) month retro-period must be unpaid as of the date the agency received the request, unless it was incurred in a month that Medicaid LTSS coverage was active.(2) An expense incurred while Medicaid LTSS is active may be paid or unpaid.3. Limits - If all of the above conditions apply, the expense may still not be allowed in certain circumstances:a. Expense in penalty period. An expense cannot be deducted for an LTSS service incurred during a penalty period in due to an uncompensated transfer. However, non-LTSS expenses, such as primary, acute or subacute care services incurred during a period of ineligibility, may be an allowable expense if all other conditions are met.b. Used for other reductions. The expense must not have been treated as or paid: (1) To reduce excess resources - an expense paid by an applicant to meet resource eligibility limits cannot be deducted in the income calculation.(2) As an income exclusion or deduction - an expense previously used as a deduction in the income calculation cannot be used under this section.4. Charges Not Allowed - Under current Federal Regulations, the following services are not allowable expense deductions when provided to a Medicaid applicant: a. Personal Items. Items such as shampoo, toothpaste or dental floss;b. Elective or Expanded Services. Optional or elective features to services and supports that are not medically necessary, such as a motorized wheelchair, prescription sunglasses, elective treatments or procedures for non-medical purposes;c. Provider travel. A charge for a provider to travel to an applicant's residence when no medical service is provided.5. Deduction Timeline - Allowable expenses are deducted in the LTSS income calculation for the month in which the expense is incurred. Expenses that were incurred in the three (3) months prior to the month the request for payment of LTSS services is submitted can be deducted beginning in the first month of eligibility. 6. Excess Carryover - The excess amount of an allowable expense can be carried forward and used as a deduction in future months when the amount of the expenses combined exceeds the amount of income remaining after all other deductions.210 R.I. Code R. 210-RICR-50-00-8.7
Amended effective 6/3/2021
Amended effective 9/2/2021
Amended Effective 11/3/2021
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/22/2023