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DHS clarifies Medicaid offsets for nursing-home applicants under Act 892
Summary
Mary Franklin of DHS told the Senate committee that the agency amended rules to align with a SPA and Act 892: noncovered medical expenses may offset income for Medicaid nursing-home applicants only if incurred within three months before application and meet prior-authorization and medical-necessity rules.
Mary Franklin, director of the Division of County Operations at the Department of Human Services, briefed the Senate Public Health committee on rule changes prompted by Act 892 and a Medicaid state-plan amendment.
Franklin said the amendments clarify when noncovered medical expenses may be allowed as offsets to income for nursing-facility applicants and that such expenses must generally be incurred within the three months preceding application. "Even payments for cosmetic or elective procedures will not be allowed except when they're prescribed by a medical professional," Franklin said. She added that offsets must be the least of the fee recognized by Medicaid, Medicare or the average cost allowed by commercial insurance.
DHS also clarified exclusions: expenses incurred as a result of a transfer-of-assets penalty, expenses that were not prior-authorized by applicable insurers, or procedures determined not medically necessary through prior authorization are not allowable offsets. Franklin paused for committee questions and the committee reviewed the rule without objection.
The rule aligns the department's Medicaid rules with the state plan amendment and tightens definitions so applicants, facilities and caseworkers have clearer guidance.
