For community, LTC, and SLF cases, when determining if an enrolled case meets spenddown, allow bills or receipts for the following types of medical expenses. When determining if spenddown is met, use the medical expenses of everyone included
in the Standard, even if they are not included in the Medical case.
- The estimated amount of DHS ODD/OMH Community-Based Services and DHS ORS HSP services.
- Medicare and other medical insurance premiums. Allow SMIB premiums automatically deducted by the Social Security Administration. Do not allow SMIB premiums for clients receiving QMB/SLIB/QI-1 benefits. Also do not allow health insurance premiums paid
by the Health Insurance Premium Payment (HIPP) Program.
- Deductibles, coinsurance charges, or client copayments whether paid or unpaid. Do not allow Medicare deductibles and copayment charges for enrolled QMB clients.
- Medical expenses for services or items recognized under state law, but not covered under Illinois' Medicaid Program.
- Medical expenses for services or items covered under Illinois' Medicaid Program.
- Cost-sharing amount(s) incurred by persons receiving in-home care services from the Department on Aging (DOA). See PM 20-28-02 for a description of in-home care
- The amount incurred for in-home care services purchased through a private party. See PM 20-28-02 for a description of in-home care services.
- Medical transportation expenses at 24¢ per mile, if the client provides their own transportation. For any other form of transportation, such as Medicar, taxicab, service car, or common carrier (bus, train, airplane, etc.), allow the actual cost.
- Illinois Department of Revenue Pharmaceutical Assistance Program enrollment fees and monthly deductibles.
- For AABD cases, any costs needed for securing and maintaining a service animal, such as a seeing eye dog, hearing guide dog, or housekeeping animal.
- Charges for services incurred while residing in a DHS facility during a time when the person is not eligible for Medicaid.
- For all spenddown cases, allow over-the-counter drugs or items only when ordered by a physician. Over-the-counter drugs or items include, but are not limited to, gauzes, mouthwash, aspirin, etc.
NOTE: For Long Term Care Credit cases, do not allow over-the-counter drugs or items ordered by a physician.
Only allow bills or receipts for medical expenses that are verified as being medically necessary, and for a specific amount. Medically necessary means the medical service or item is administered, provided, or prescribed by a
professional medical provider.
NOTE: 1. Do not allow routine and preventive dental services for regular medical clients living in Intermediate Care Facilities for the Mentally Retarded (ICF/MR).
2. Do not allow, as a deduction from income or when determining if spenddown is met, any bed reserve charges for a resident of an Intermediate Care Facility (ICF), Skilled Nursing Facility (SNF), ICF/MR, or Supportive Living Facility
For persons in the following community settings, room and board costs are not an allowable medical expense:
- public tuberculosis hospital; or
- residential home; or
- educational or vocational training facility; or
- rehabilitation facility that is not a medical facility; or
- facility that is not a licensed medical or sheltered care facility.