Current through Register Vol. 39, No. 6, September 16, 2024
(a) Patient
liability shall apply to clients who live in facilities for skilled nursing,
intermediate nursing, intermediate care facility for individuals with an
intellectual disability, or other medical institutions.
(b) The client's patient liability for cost
of care shall be computed as a monthly amount after deducting the following
from his or her total income:
(1) An amount
for his or her personal needs as established under the Medicaid State
Plan;
(2) Income given to the
community spouse to provide him or her a total monthly income from all sources,
equal to the "minimum monthly maintenance needs allowance" as defined in
42 U.S.C.
1396r-5(d)(3)(A);
(3) Income given to family members described
in 42 U.S.C.
1396r-5(d)(1), to provide
each, from all sources of income, a total monthly income equal to:
(A) One-third of the amount established under
42 U.S.C.
1396r-5(d)(3)(A)(i);
or
(B) Where there is no community
spouse, an amount for the number of dependents, based on the income level for
the corresponding budget unit number, as approved by the NC General Assembly
and stated in the Appropriations Act for categorically and medically needy
classifications;
(4) The
income maintenance level provided by
42 U.S.C.
1396r-5(d)(3)(A)(i) or State
statute for a single individual in a private living arrangement with no spouse
or dependents at home, for whom the physician of record has provided a written
statement that the required treatment is such that the patient is expected to
return home within six months, shall be allowed by the county department of
social services; and
(5) An amount
for unmet medical needs as determined under Paragraph (f) of this
Rule.
(c) Patient
liability shall apply to institutional charges incurred from the date of
admission or the first day of the month and shall not be prorated by days if
the client lives in more than one institution during the month.
(d) The county department of social services
shall notify the client, the institution, and the State of the amount of the
monthly liability and any changes or adjustments.
(e) When the patient liability as calculated
in Paragraph (b) of this Rule exceeds the Medicaid reimbursement rate for the
institution for a 31-day month:
(1) The
patient liability shall be the institution's Medicaid reimbursement rate for a
31-day month; and
(2) The client
shall be placed on a deductible determined in accordance with regulations,
Rules .0208 and .0209 of this Section, and the Medicaid State Plan.
(f) The amount deducted from
income for unmet medical needs shall be determined as follows:
(1) Unmet medical needs shall be the costs
of:
(A) Medical care covered by the program
that exceeds limits on coverage of that care and is not subject to payment by a
third party;
(B) Medical care
recognized under State and federal tax law that is not covered by the program
and that is not subject to payment by a third party; and
(C) Medicare and other health insurance
premiums, deductibles, or coinsurance charges that are not subject to payment
by a third party.
(2)
The amount of unmet medical needs deducted from the patient's monthly income
shall be limited to monthly charges for Medicare and other health insurance
premiums.
(3) The actual amount of
incurred costs that are the patient's responsibility shall be deducted when
reported from the patient's liability for one or more months.
(4) Incurred costs shall be reported by the
end of the six-month Medicaid certification period following the certification
period in which they were incurred.
Authority
G.S.
108A-54;
108A-54.1B;
42 C.F.R.
435.733;
42 C.F.R. 435.831;
42 C.F.R.
435.832;
42 U.S.C. 1396r-5;
Eff. September 1, 1984;
Amended Eff. September 1, 1994; March 1,
1991; August 1, 1990; March 1, 1990;
Transferred from
10A NCAC
21B .0407 Eff. May 1, 2012;
Readopted Eff. June 1, 2019.
