An eligibility unit (EU) is entitled to the excess medical deduction if the allowable medical expense is incurred by:

• an elderly or disabled EU member;
  
  
• any elderly or disabled individual who would be an EU member except he/she is hospitalized, in a nursing home (ICF, SNF), or deceased if the EU is responsible for the expense; or
  
  
• persons receiving the following SSI presumptive disability payments and SSI emergency advance payments.

Medical expenses are recorded separately for each EU member incurring medical expenses on the Medical Expense (FMXA) screen. Enter the appropriate type code in the "Type" field, the entire amount of the medical expense in the "Amount" field, and type or prompt for the frequency the expense is incurred in the "Freq" field. FAMIS then calculates the monthly expense based on the amount and frequency entered. When more than one EU member incurs medical expenses, FAMIS totals the expenses for all EU members entitled to a medical expense deduction, deducts $35 from the total expenses, and budgets the appropriate amount.

NOTE : Elderly or disabled EUs have a suggested certification of 24 months. There is no frequency code for 24 months. At certification, when entering a one-time medical expense that is prorated over a 24-month certification, divide the expense in half. Enter half of the expense in the "Amount" field and select the frequency "Annually" so FAMIS can correctly calculate the medical deduction. (Procedures for entering medical expenses reported during a 24 month certification period are described in Changes or Pays or Intends to Pay at Billing). The other alternative is to change the suggested certification to 12 months and prorate the entire expense over the 12-month certification. Enter a comment explaining how and why the expense is budgeted as it is.

EXAMPLE: Ms B. had a medic alert system installed and her out-of-pocket expense is $1200. Ms. B. chooses to average it over the 24-month certification period. Since there is no 24-month frequency code, the worker must divide the expense by two and enter $600 in the amount field and enter the code for “annually” in the “Freq” field. FAMIS then calculates the deduction for each month which results in $50 monthly less $35. The Budget Summary (FM4A) shows $15 per month excess medical expense.

When the EU is responsible for medical expenses for an elderly or disabled individual who would be an EU member except he/she is hospitalized, in a nursing home (ICF, SNF), or deceased, total the expenses and show them as expense type NM (medical expense for non-household member)) on the Medical Expense (FMXA) screen for the head of EU. Record the type and amount of each medical expenses included in the total on the Comments screen. FAMIS will include the expense even when the EU member with the expense is not an elderly or disabled individual.

Only one entry per type of expense is allowed on the Medical Expense screen. If more than one expense of the same type is entered, FAMIS only uses the last expense when determining the excess medical deduction. When an EU member has more than one expense of the same type, for example three prescriptions per month, total the expenses and enter the total amount in the "Amount" field.

Always review the Budget Summary (Food Stamps) screen (FM4A) prior to authorizing a case action. From the Budget Summary screen, press F15=EXPSUMM to review the Expense Summary (FM34) screen to ensure expenses you expect to be budgeted are included in the budget. If the expense is incorrect, return to the Medical Expense (FMXA) screen and correct the expense.

The following provides an overview of Food Stamp Program budgeting methods for medical deductions.

ONGOING EXPENSES

Budget ongoing expenses in the following manner.

• Non-fluctuating recurring monthly expense: The EU can choose to either budget the entire amount in the month billed or budget agreed upon monthly installments .

  EXAMPLE : Mr. L bought dentures and was billed for them in December. The total cost for the dentures was $2400. Mr. L reported this expense and provided verification in December. Mr. L. has set up a payment plan and will pay $100 per month for the next 24 months. Mr. L is not being charged interest. Mr. L. may choose to have the entire $2400 budgeted for the month of January or the monthly installments of $100 budgeted. Mr. L. may also have a third option if he is certified for 24 months and the expense was reported during the first twelve months of his certification. He may choose to average the expense over the remainder of the first 12 months. If Mr. L. chooses the third option, set a reminder to remove the expense at the end of 12 months.

• Fluctuating : The EU can choose to budget the entire amount in the month billed, or average over the certification period (the EU can request a change in budgeting method once during the certification period).

  EXAMPLE : Ms. M. requires housekeeping services due to her health. Her housekeeper cleans her house every Monday. Ms. M pays $25 per week for this service. Because there are five Mondays in some months, this expense fluctuates. Ms. M can elect to have the entire amount budgeted in the month billed or averaged over the certification period.

• Changes: Factor changes that can be anticipated and verified into the expense calculation.

  EXAMPLE : Mr. N is applying for food stamps in the month of December. Mr. N has a Medicare supplement plan. He is currently paying $75 per month for this plan. Mr. N received a notice from the insurance company that his monthly premium will increase to $90 per month in January. Mr. N provided his new premium payment book verifying the increased expense. Enter $75 for insurance expense on the Medical Expense screen for the month of December and end date the expense in December. Add the $90 expense for the month of January. FAMIS will calculate the medical deduction using $75 for the month of December and $90 beginning in the month of January. If the new expense will begin more than two months in the future, set a reminder to update the medical expense.

If the EU chooses to budget for one month, enter the entire expense in the "Amount" field on the Medical Expense (FMXA) screen. Type the current month in both the "Begin" and "End" date fields. Type or prompt for MTH (monthly) in the"Frequency" field. FAMIS uses the entire expense for one month only.

If the EU chooses to budget over the certification period, enter the entire expense in the “Amount” field. Do not enter an end date. Type or prompt for the appropriate code for the number of months in the certification period in the “Frequency” field.

If the EU is certified for 24 months and less than 24 months remain in the certification period, divide the expense by 24 and enter 1/24 of the expense in the “Amount” field. Type or prompt for the Frequency code MTH (monthly). Complete all other required fields. FAMIS allows the expense each month for the duration of the certification.

ONE TIME EXPENSES

Budget one time expenses in the following manner.

• Pays or intends to pay at billing : The EU can choose to budget for one month or average over the remainder of the certification period (the EU can request a change in budgeting method once during the certification period).
  
  
  • If the EU chooses to budget for one month, enter the entire expense in the "Amount" field on the Medical Expense (FMXA) screen. Type the current month in both the "Begin" and "End"date fields. Type or prompt for MTH (monthly) in the "Frequency" field. FAMIS uses the entire expense for one month only.
    
    
  • If the EU chooses to budget over the remainder of the certification period, enter the entire expense in the"Amount" field. Do not enter an end date. Type or prompt for the appropriate code for the number of months in the certification period in the "Frequency" field.
    
    
  • If the EU is certified for 24 months, divide the expense by 24 and enter 1/24 of the expense in the "Amount" field. Type or prompt for the Frequency code MTH (monthly).
    
    
  • Complete all other required fields. FAMIS allows the expense each month for the duration of the certification.
    
    EU’s certified for 24 months have a third option when the medical expense is reported during the first 12 months of the certification period. The EU may average the expense over the remainder of the first 12 months.
    
    
  • To average the expense over the remainder of the first 12 months of the certification period, determine the number of months remaining in the first 12 months of the certification period.
    
    
  • If there are more than two months remaining in the first twelve months of the certification period, enter the entire expense in the "Amount" field on the Medical Expense (FMXA) screen.
    
    
  • If there are two months remaining in the first 12 months of the certification period, divide the expense in half and enter that amount in the "Amount" field. Type or prompt for the frequency code that represents the number of months remaining in the first twelve months of the certification in the "Frequency" field.
    
    
  • If there is only one or two months remaining in the first 12 months of the certification, enter the expense as a monthly expense and type the last month the expense should be budgeted in the "End" field.
    
    
  • Complete all other required fields. Set a reminder to remove the medical expense at the end of the 12 th month when there are more than two months remaining in the first twelve months of the certification.
    
    
• Takes out a loan: Budget the monthly payment on the principal; do not include interest.
  
  
• Enter the amount paid monthly on the principal in the "Amount" field on the Medical Expense (FMXA) screen. Type or prompt for the MTH (monthly) frequency code.
  
  
• Complete all other required fields. If the loan will be paid in full prior to the end of the certification, set a reminder to end date the payment in the last month in which it will be made.

• Establishes payment plan/pays installments : Budget the monthly payment amount if the plan was established before the due date of the bill. Installments may be formal or informal agreements.
  
  
  • Enter the amount paid monthly in the "Amount" field on the Medical Expense (FMXA) screen. Type or prompt for the MTH (monthly) frequency code.
    
    
  • Complete all other required fields. If the installments will be paid in full prior to the end of the certification, set a reminder to end date the expense in the last month in which the payment will be made.
    
    
• Renegotiation of payments : Budget the new amount if the originally agreed upon amount is not past due. Budget the originally agreed upon amount if the payment is past due.
  
  
  • Enter the amount of the renegotiated payment in the “Amount” field on the Medical Expense (FMXA) screen. Type or prompt for the appropriate frequency code in the “Frequency” field.
    
    
  • Complete all other required fields.

THIRD PARTY LIABILITY

 Medical expenses involving third party reimbursement are not considered past due until 30 days after the third party reimbursement is verified.

• spend down : Only those expenses actually incurred or that can be reasonably anticipated are allowed as a medical expense.

• Enter each type of expense incurred by the participant to meet spend down on the Medical Expense (FMXA) screen. Enter the total amount incurred for each type of expense in the “Amount” field. Type or prompt for frequency code MTH (monthly) in the frequency field.

• Enter the amount paid in by those individuals who elect to pay-in their monthly spend down amount as expense type MC (insurance co-pay/spend down expense) in the type field. Enter the amount paid in the “Amount” field. Type or prompt for frequency code MTH (monthly) in the frequency field.

• If the individual stops paying in the spend down amount or does not meet spend down, end date the expense on the Medical Expense (FMXA) screen and complete an eligibility determination.
  
  
• Do not allow the spend down amount paid in by a vendor on behalf of the participant as a medical expense. After meeting spend down, budget allowable expenses not covered by Medicaid. The participant has the option to have expenses incurred prior to spend down and expenses not covered by Medicaid averaged over the certification.
  
  
• Other (insurance, Medicare, QMB): Wait until amount paid by third party is verified. Then, budget the allowable expense not covered by the third party. Budget based on the type of expense and method of payment. Refer to the appropriate section above based on the type of expense or method of payment for instructions on entering the expense not covered by the third party on the Medical Expense (FMXA) screen.

Note Budget the SMI premium as a medical expense until the SMI premium is no longer deducted from the from the Social Security payment, even if the individual will later be reimbursed for the premiums. Set a priority to check IIVE for the removal of the premium. When this has been verified, remove the Medicare premium expense for the first month an EU member is no longer making the payment after becoming eligible for QMB or SLMB (SM, PD).