DEDUCTIBLE CALCULATION

Maximum Income Table

Medicaid Deductibles are either prospective or retrospective and are met with accumulated medical bills.

Prospective deductibles are calculated by taking the households net income and then subtracting the maximum income amount for the household size and then multiplying times six (prospective deductibles are always 6 months long):

Example one person with $750 Social Security income

[($750-20)-242] X 6 = $2,928

Thus this person will need $2,928 in medical expenses during the 6 month deductible period before receiving Medicaid for the remainder of the deductible period.

Retrospective Deductibles are calculated by taking the households net income and then subtracting the maximum income amount for the household size and then multiplying times 1, 2 or 3 (retrospective deductibles can be 1, 2 or 3 months back):

Example one person with $750 Social Security income

[($750-20)-242] X 1 = $488

Thus this person will need $488 in medical expenses during the 1 month deductible period before receiving Medicaid for the remainder of the 1 month period.

How do I meet the deductible?

A Medicaid deductible is met by adding up medical costs on a day by day basis. When a Medicaid applicant pays or is billed for medical care, supplies and prescriptions, he has incurred these costs and may have them applied to his deductible. Only the portion of the bill that the person must pay can be applied to the deductible. (For example, a person with health insurance may only be responsible for 10% or $50 of a $500 bill. Fifty dollars is the amount that can be applied to meet the Medicaid deductible.) You can be authorized for Medicaid on the date that the bills add up to the amount of the deductible.

Whose Income/Medical Bills are Counted Toward the Deductible?

In Medicaid, your spouse's income must be counted in determining eligibility. Likewise, a parent's income must be counted when determining eligibility for a child. Because these individuals’ income is counted, their medical bills may be applied to the Medicaid deductible. 

You can meet the Medicaid deductible with medical bills that are your responsibility to pay from your own money. You cannot use bills that someone else pays for you or that insurance pays. If insurance pays part of the bill and you must pay the rest, you can use the part you have to pay to help meet your deductible.

If you have a large medical expense or if you are close to meeting your deductible, take your bills to Social Services as soon as you get them. You cannot receive a blue card for full Medicaid benefits until this deductible is met. The following can be used to meet your Medicaid deductible. You may want to provide your worker at social services with information on these items.

A. An unpaid medical bill which was charged to you before your 6 months certification period may be used to meet your deductible. In order to use this bill, your worker must verify certain things.
 

1. It must be less than 2 years old.

2. If over 2 years old, you must have made a payment on it within the past 2 years.

3. It must be unpaid and the medical provider is still billing you.

4. All medical insurance you had at the time must have been filed and either paid or denied payment for the bill.

5. If you borrowed money to pay off a medical bill, you should let your worker know so that he or she can see if you can use it to meet your deductible.

6. Once you use an unpaid medical bill for your deductible it cannot be used again on another deductible.

1. Hospital charges

2. Clinic and laboratory charges

3. Charges for physicians (doctors), dentists, and therapy

4. Prescription drug charges

5. "Over-the-counter" medicines and medical supplies from the drug store. For instance, non-prescription drugs such as aspirin, Tylenol, Pepto-Bismol, Benadryl, cold medicines, etc., and medical supplies such as gauze. Bandaids, bandages, needles for necessary medical injections, absorbent pads for the incontinent, alcohol, etc.

6. Examples of some other medical expenses that can be used are:

Medically related transportation costs, dentures, eyeglasses, hearing aids, walkers, wheelchairs, crutches, braces, and other medical equipment, and dietary supplements, such as Ensure, if prescribed by your doctor.

7. Premiums you pay for private health insurance can usually be used to meet your deductible.
 

C. Ask your worker about any medical expenses not listed or that you are not sure of. In order to use "over-the-counter" medicines and medical supplies and some other expenses, you must have a receipt which clearly shows the item purchased, the date, and the cost. If your cash register receipt does not give this information, ask for a handwritten receipt.

D. Always ask the worker to make a copy of your bills so that you can keep the original for your own records.