Third Party Payment Example
Let’s apply this policy to Sam Ribble’s case.
As you recall Sam’s health care coverage was expected to pay $1,000 of his February, March, April and May LTCF charges. At the time of Sam’s six-month renewal a DAIL/TIKL was received to update his carry forward expenses into the next certification period and to follow-up on whether his insurance had paid the estimated amount on his LTCF bills. Sam submitted EOMBs for each of the four months that showed his insurance company actually paid $2,000 for each month.
We also anticipated that MA will not cover the over-the-counter vitamin expense for May. Sam provided a statement from the pharmacy that MA does not cover the vitamin expense.
Action:
Update the DHS-6059B (PDF) with the new actual amounts that Sam is responsible for. Based on this update, the carry forward amount for the next certification period changes and Sam is allowed a medical expense through February of the next year, rather than March. MAXIS STAT/BILS must be updated with the deduction amount for the next certification period.Once eligibility is approved, send an updated version of the DHS-6059C (PDF) to Sam to explain the updates made to his deduction.
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The MA-LTC Medical Expense Deduction - Case Maintenance