Allowable Medical Expenses for Client Responsibility Calculation

D08-007– Procedure

June 1, 2008

TO: / Regional Administrators
Field Services Administrators
Central Office Program Managers
FROM: / Linda Rolfe, Director, Division of Developmental Disabilities
SUBJECT: /

Allowable medical expenses for Client Responsibility calculation

Purpose: / To provide guidance to Field Services staff regarding what expenses may be deducted from income when calculating Client Responsibility for DDD authorized services in compliance with DDD Policy 6.06, Client Responsibility.
Background: / In Title 42CFR435.726, the Centers for Medicare and Medicaid Services (CMS) allow the cost for certain medical expenses to be deducted from a client’s income when calculating the amount a client must pay toward the cost of his/her services.
However, neither the CFR, RCW 71A.12.070, nor WAC 388-515-1510 provides specific guidance as to what is an allowable medical expense.
This management bulletin provides clarification on what expenses may be allowed as medical deductions for the purpose of calculating Client Responsibility as described in DDD Policy 6.06, Client Responsibility.
What’s new, changed, or
Clarified / Expenses that are not allowed:

• Those that are covered by a third-party payer, including Medicare, Medicaid, or private insurance; and

• Those that are included in a DDD waiver when the client is covered under that waiver.

Other expenses that arenot allowed:

• Medications (prescription or OTC) not covered by Medicaid;

• Supplements (vitamins, minerals, etc.; see WACs below);

• Food or supplies for special diets;

• Utility bills;

• Environmental modifications.

Expenses that will be allowed:

• The following items or services covered by Medicaid when the client requires more of these items/services than is covered by Medicaid:

• Orthotics;
• Diapers;
• Hearing aids;
• Eye glasses;
• Physical therapy;
• Occupational therapy;
• Speech therapy;
• Fluoride treatments; and
• Dentures/Partials/Implants;

• Additional software for Medicaid covered communication devices;

• Premiums, deductibles, or co-pays for Medicare or other health insurance; and

• Orthodontic services for adults with medical conditions covered in WAC 388-535A-0040.

ACTION: / When the DDD Case Resource Manager (CRM) receives copies of receipts for allowable expenses, the cost of those expenses may be deducted from available income when calculating Client Responsibility:

• A denial of payment by the available third-party payer is required before the expense is allowed as a deduction; and

• Recommendation from a primary care provider or related health care professional is required for documentation of client specific need that is evidence based

Deductions for items/services not on the list of allowable expenses may only be permitted by approval at the regional level:

• Each region must have written procedures outlining how these requests are to be processed and approved; and

• Each deduction for expenses not on the list of allowable expenses must show documentation that the regional procedure was followed.

Related
REFERENCES: / DDD Policy 6.06, Client Responsibility
WAC 388-501-0060, Healthcare coverage – Scope of covered categories of service
WAC 388-530-2000 & 2100, Covered and noncovered outpatient drugs.
ATTACHMENT(S): / None
CONTACT(S): / Linda Lunsford, 360-725-3440,
Christie Seligman, 360-725-3445,
Debbie Johnson, 360-725-3525,
Dave Langenes, 360-725-3456,

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