An eligibility unit (EU) is entitled to the excess medical deduction if the allowable medical expense is incurred by:
SSI presumptive disability payments: regular benefits for a three-month period are paid to persons most likely to meet SSI disability criteria; these are considered SSI eligible by SSA and receive a federal SSI check for the amount of entitlement.
If a medical expense is allowed for a person receiving SSI based on presumptive eligibility, and eligibility is later terminated, remove the medical deduction from the Medical Expense (FMXA) screen. If the individual’s categorical eligibility status changes, update the Categorically Eligibile (FMMK) screen. Also, update the Disabled (FMMX) screen.
NOTE: Spouses or other persons receiving benefits as a dependent of the above SSI recipients are not eligible to receive this deduction. SSI essential persons do not qualify for a medical deduction.
Disabled EU members must be coded as disabled, have a valid disability reason for food stamps, and the disability must be verified on the Disabled (FMMX) screen before FAMIS will recognize the person as being disabled and allow the excess medical deduction. If an EU member claims a disability but verification of the disability is not provided, the application can be processed with no verification of disability and the medical expenses are not allowed.
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.
FAMIS determines the medical expense deduction as follows:
EXAMPLE: Mr. and Mrs. A are both entitled to medical deductions. The medical expense for each individual is entered on the Medical Expense (FMXA) screen. Mr. A has $18 in expenses and Mrs. A has $18 in expenses for a total of $36 in expenses. FAMIS then totals both persons monthly expenses. The amount over the $35 excess medical deduction is $1; therefore the household is eligible for the $170 medical expense standard.
EXAMPLE: Mr. 0 has three monthly prescriptions at a total cost of $75 for all three. Enter $75 in the “Amount” field on FMXA. Type or prompt for the “Freq” code for monthly. FAMIS then calculates the medical deduction by subtracting $35 from the $170 medical expense standard.
Refer to the Budgeting Medical Expenses procedure guide for instructions on how to enter the medical expenses in FAMIS.
Prior to certification, verify deductible medical expenses totaling more than $35 per month, anticipated to be incurred during the certification. The following types of medical costs are allowed. The expense codes used on the Medical Expense (MEDEXP/FMXA) screen follows each in parenthesis.
Allow transportation costs for trips to a pharmacy or other location to fill prescriptions.
NOTE: Budget the SMI premium until the SMI premium is no longer deducted from the Social Security payment, even if the individual will later be reimbursed for the premiums.
NOTE: Allow transportation costs for trips to a pharmacy or other location to fill prescriptions.
NOTE: Special diets are not an allowable medical cost.
Any medical expense that will be covered by a third party liability (TPL) reimbursement or an excluded vendor payment is not allowed as a deduction. The portion of the medical expense not covered by TPL or excluded vendor payments is allowed as a medical expense to the EU. TPL includes Medicare, Medicaid, or other health insurance.
EXAMPLE : Mr. M., who is entitled to medical deductions, has total medical expenses of $635 and has Medicare. Mr. M. receives the medical bill for $635 in February. In June Medicare pays $400 on the bill. Mr. M. is then responsible to pay $235. After verifying the third party payment has been made, enter the medical expense of $235 on the Medical Expense screen. This amount can be allowed in one lump sum the month in which it is verified, averaged over the certification period, or according to a negotiated payment plan. If the medical deduction is averaged over the certification period, the total amount for which Mr. M. is responsible to pay ($235) is averaged. If Mr. M. is certified for 24 months, is in the first 12 months of his certification, and chooses to average the expense over the remainder of his certification, divide the expense by the number of months remaining in the certification. Enter the prorated amount on the Medical Expense (FMXA) screen and frequency code monthly as there is no frequency code for more than 12 months. If Mr. M. is certified for 24 months and is in the first 12 months of his certification period, he has a third option of averaging the expense over the remainder of the first 12 months. FAMIS excludes the first $35 from the averaged amount to arrive at the monthly allowable medical deduction.
NOTE: If Mr. M. chooses to average the expense over the remainder of the first 12 months, set a reminder to remove the expense at the end of 12 months.
EXAMPLE : Ms. L. is billed $1000 in May for an allowable medical expense. The bill is submitted to the insurance company. On July 12, Ms. L. is notified that the insurance company paid $800. Ms. L. is responsible for paying $200 of the expense. The bill is not past due until August 11 or the date supplied on the billing notice.
Any medical expense that will be paid as a qualified disability expense from an ABLE account is not allowed as a cost for the excess medical deduction.
Budget an allowable expense as long as a payment plan was made or loan applied for by the due date of the original billing. (Refer to example below.) Otherwise, consider the expense past due and do not budget it. A bill is considered past due either as indicated on the bill, or, as a general rule, 30 days after the billing date, or 30 days after the date of TPL reimbursement. (Past due is the date the payment is overdue to the provider.)
EXAMPLE: Ms. Z. incurred an expense of $1000. The original bill is received on 5/1. By 5/30, the EU has arranged with the hospital to pay $100 each month from June through March. The $100 is entered on the Medical Expense screen. FAMIS excludes the first $35 each month as a deduction for the next ten months allowing Ms. Z the $200 medical expense standard. If the EU is certified beyond March, set a reminder to remove the medical expense and run a new eligibility determination for the month of April through the remainder of the certification.
Medical expenses are budgeted either as ongoing expenses or one time expenses and can include fluctuating expenses, changes to expenses, loans, and responsibility after third party payments
Refer to the procedure guide Budgeting Medical Expenses for further instructions regarding entry in FAMIS and procedures for budgeting medical expenses.