Current through Register Vol. 39, No. 6, September 16, 2024
(a) A deductible
shall apply to a client in the following arrangements:
(1) In private living quarters in the
community;
(2) In a residential
group facility; or
(3) In a
long-term care living arrangement when the client:
(A) Has enough income monthly to pay the
Medicaid reimbursement rate for 31 days, but does not have enough income to pay
the private rate plus all other anticipated medical costs;
(B) Is under a sanction due to a transfer of
resources as specified in the Medicaid State Plan;
(C) Does not yet have documented prior
approval for Medicaid payment of nursing home care;
(D) Resided in a facility in the facility's
month of certification;
(E) Chooses
to remain in a decertified facility beyond the last date of Medicaid payment;
or
(F) Is under a Veterans
Administration (VA) contract for payment of cost of care in the nursing
home.
(b) The
client or his or her representative shall be responsible for providing bills,
receipts, insurance benefit statements, or Medicare EOBs to establish incurred
medical expenses and his or her responsibility for payment. If the client has
no representative and he or she is physically or mentally incapable of
accepting this responsibility, the county department of social services shall
assist him or her in obtaining verification.
(c) Expenses shall be applied to the
deductible when they meet the following criteria:
(1) They are for medical care or service
recognized under State or federal tax law;
(2) They are incurred by a budget unit
member; and
(3) They are incurred:
(A) During the certification period for which
eligibility is being determined and the requirements of Paragraph (d) of this
Rule are met; or
(B) Prior to the
certification period and the requirements of Paragraph (e) of this Rule are
met.
(d)
Medical expenses incurred during the certification period shall be applied to
the deductible if the requirements in Paragraph (c) of this Rule are met and:
(1) The expenses are not subject to payment
by any third party including insurance, government agency or program, except
when the program is entirely funded by State or local government funds, or
private source;
(2) The private
insurance has not paid the expenses by the end of the application time
standard;
(3) For certified cases,
the insurance has not paid by the time that incurred expenses equal the
deductible amount; or
(4) The third
party has paid and the client is responsible for a portion of the
charges.
(e) The unpaid
balance of a medical expense incurred prior to the certification period shall
be applied to the deductible if the requirements in Paragraph (c) of this Rule
are met and:
(1) The medical expense was:
(A) Incurred within 24 months immediately
prior to:
(i) The month of application for
prospective or retroactive certification period or both; or
(ii) The first month of any subsequent
certification period; or
(B) Incurred prior to the period described in
Part (e)(1)(A) of this Rule, and a payment was made on the bill during that
period; and
(2) The
medical expense:
(A) Is a current
liability;
(B) Has not been applied
to a previously met deductible; and
(C) Insurance has paid any amount of the
expense covered by the insurance.
(f) The county department of social services
shall apply incurred medical expenses to the deductible in chronological order
of charges except that:
(1) If medical
expenses for Medicaid covered services and non-covered services occur on the
same date, apply charges for non-covered services first;
(2) If both hospital and other covered
medical services are incurred on the same date, apply hospital charges first;
and
(3) If a portion of charges is
still owed after insurance payment has been made for lump sum charges, compute
incurred daily expense to be applied to the deductible as follows:
(A) Determine the average daily charge,
calculated by adding the charges and dividing by the number of days, excluding
discharge date from hospitals;
(B)
Determine the average daily insurance payment, calculated by adding the
insurance payments and dividing by the number of days, for the same number of
days; and
(C) Subtract average
daily insurance payment from the average daily charge to establish client's
daily responsibility.
(g) Eligibility shall begin on the day that
incurred medical expenses reduce the deductible to $0, except that the client
is financially liable for the portion of medical expenses incurred on the first
day of eligibility that were applied to reduce the deductible to $0. If
hospital charges were incurred on the first day of eligibility, notice of the
amount of those charges applied to meet the deductible shall be sent to the
hospital for deduction on the hospital's bill to Medicaid.
(h) The receipt of proof of medical expenses
and other verification shall be documented by the county department of social
services in the case record.
Authority
G.S.
108A-54;
108A-54.1B;
42 C.F.R.
435.831; Alexander v. Flaherty, U.S.D.C.,
W.D.N.C., File Number C-C-74-483; Alexander v. Flaherty Consent Order filed
February 14, 1992;
Eff. September 1, 1984;
Amended Eff.
June 1, 1994; September 1, 1993; April 1, 1993; August 1, 1990;
Transferred from
10A NCAC
21B .0406 Eff. May 1, 2012;
Readopted Eff. June 1, 2019.
