R414-304-11. Aged, Blind and Disabled Institutional Medicaid and Family Institutional Medicaid Income Deductions

  (1) The Department shall determine income deductions based on the financial methodologies in 42 CFR 435.601 and the deductions defined in 42 CFR 435.725, 435.726, 435.832, and 42 USC 1396a(r)(1), and 1396r-5(d).

  (2) Health insurance premiums:

  (a) For institutionalized and waiver eligible clients, the eligibility agency shall deduct from income health insurance premiums only for the institutionalized or waiver eligible client and only if paid with the institutionalized or waiver eligible client's funds. The eligibility agency shall deduct premiums the Department is paying on behalf of the client as authorized by Section 1905(a) of Title XIX of the Social Security Act, except no deduction is allowed for Medicare premiums that the Department pays for recipients.

  (b) For Aged, Blind and Disabled programs, the eligibility agency shall deduct health insurance premiums in the month the payment is due.

  (c) For Medically Needy Family, Pregnant Woman and Child programs, factor premiums due weekly or bi-weekly before deducting. For payments due on any other basis, deduct the actual amount in the month due.

  (d) The eligibility agency shall deduct from income the portion of a combined premium attributable to the institutionalized or waiver-eligible client if the combined premium includes a spouse or dependent family member. The client's portion must be paid from the funds of the institutionalized or waiver-eligible client.

  (3) The eligibility agency may only deduct medical expenses from income under the following conditions:

  (a) the client receives the medical service;

  (b) Medicaid or a third party will not pay the medical bill;

  (c) a paid medical bill can only be deducted through the month of payment. No portion of any paid bill can be deducted after the month of payment.

  (4) The eligibility agency may not deduct from income to determine cost-of-care contribution for long-term care services, or when a client incurs expenses for medical or remedial care services, even if the expense remains unpaid when:

  (a) a client is in a penalty period resulting from a transfer of assets; or

  (b) a client's residential home exceeds the equity value as defined in 42 U.S.C. 1396p(f).

  (5) The eligibility agency may not allow a medical expense as an income deduction more than once.

  (6) The eligibility agency may only allow as an income deduction a medical expense for a medically necessary service. The eligibility agency shall determine whether the service is medically necessary.

  (7) The eligibility agency may only deduct the amount of prepaid medical expenses equal to the cost of services received during the month in which the client pays the expenses. The eligibility agency may not deduct from income any payments a client makes for medical services in a month before the client receives the service.

  (8) When a client must meet a spenddown to become eligible for a medically needy program or receive Medicaid under a home and community based care waiver, the client must sign a statement that says:

  (a) the eligibility agency told the client how spenddown can be met;

  (b) the client expects his or her medical expenses to exceed the spenddown amount;

  (c) whether the client intends to pay cash or use medical expenses to meet the spenddown; and

  (d) the eligibility agency told the client that Medicaid providers may not use the provider's funds to pay the client's spenddown or loan the client money for the client to pay the spenddown.

  (9) A client may meet the spenddown by paying the eligibility agency, or by providing proof to the eligibility agency of medical expenses the client owes equal to the spenddown amount.

  (a) The client may elect to deduct from countable income unpaid medical expenses for services the client receives in non-Medicaid-covered months to meet or reduce the spenddown.

  (b) Expenses must meet the criteria for allowable medical expenses.

  (c) Expenses may not be payable by Medicaid or a third party.

  (d) For each benefit month, the client may choose to change the method of meeting spenddown by either presenting proof of allowable medical expenses to the eligibility agency or by making a payment to the eligibility agency equal to the spenddown amount.

  (10) The eligibility agency may not accept spenddown payments from a Medicaid provider if the source of the funds is the Medicaid provider's own funds. In addition, the eligibility agency may not accept spenddown payments from a client if a Medicaid provider loans funds to the client to make a spenddown payment.

  (11) The eligibility agency shall require institutionalized clients to pay all countable income remaining after allowable income deductions to the institution in which an individual resides, as the individual's cost-of-care contribution.

  (12) A client who pays a cash spenddown or a cost-of-care amount to the medical facility in which he resides, may present proof of medical expenses paid during the coverage month and request a refund of spenddown or cost-of-care paid up to the amount of bills. The following criteria apply:

  (a) Expenses for which a refund can be made include medically necessary medical expenses not covered by Medicaid or any third party, co-payments required for prescription drugs covered under a Medicare Part D plan, and co-payments or co-insurance amounts for Medicaid-covered services as required under the Utah Medicaid State Plan;

  (b) The expense must be for a service the client receives during the benefit month;

  (c) The eligibility agency may not refund any portion of a medical expense the client uses to meet a Medicaid spenddown or to reduce his cost-of-care to the institution when the client assumes that payment responsibility;

  (d) A refund cannot exceed the actual cash spenddown or cost-of-care amount paid by the client;

  (e) The eligibility agency may not refund a spenddown or cost-of-care amounts paid by a client based on unpaid medical expenses for services the client receives during the benefit month. The client may present to the eligibility agency any unpaid bills for non-Medicaid-covered services the client receives during the coverage month. The client may use these unpaid bills to meet or reduce the spenddown the client owes for a future month of Medicaid coverage to the extent the bills remain unpaid at the beginning of the future month, and the bills are not payable by a third party;

  (f) The Department shall reduce a refund by the amount of any unpaid obligation the client owes the Department.

  (13) The eligibility agency shall deduct a personal needs allowance for residents of medical institutions equal to $45.

  (14) When a doctor verifies a single person or a person whose spouse resides in a medical institution is expected to return home within six months of entering a medical institution or nursing home, the eligibility agency shall deduct a personal needs allowance equal to the BMS for one person defined in Subsection R414-304-13(6), for up to six months to maintain the individual's community residence.

  (15) A client is not eligible for Medicaid coverage if medical costs are not at least equal to the contribution required towards the cost of care.

  (16) Medical costs a client incurs in a benefit month may not be used to meet a spenddown when the client is enrolled in a Medicaid health plan.

  (17) Bills for mental health services a client incurs in a benefit month may not be used to meet a spenddown if Medicaid contracts with a single mental health provider to provide mental health services to all recipients in the client's county of residence.

  (18) Bills for mental health services a client pays in a retroactive or application month may be used to meet a spenddown if the services are not provided by a Medicaid-contracted mental health provider.