PM 15-08-05: Allowable Medical Expenses

WAG 15-08-05.

Deleted textFor community, NH, 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 DoA Services and DHS DDD Community-Based Services and DHS DRS HSP Services.
  • Medicare and other medical insurance premiums. Allow SMIB premiums automatically deducted by the Social Security Administration. Do not allow SMIB premiums for customers receiving QMB/SLIB/QI-1 benefits. Also do not allow health insurance premiums paid by the Health Insurance Premium Payment (HIPP) Program. Allow premiums for dental coverage and eye care only if the plan covers services not covered by the medical card. If a community spouse is paying for health insurance of the LTC spouse, allow the portion of the premium paid for the LTC customer's coverage if it can be separately identified. 
  • Deductibles, coinsurance charges, or customer copayments whether paid or unpaid. Do not allow Medicare deductibles and copayment charges for enrolled QMB customers.
  • 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. Only allow receipts for services where the cost was the responsibility of the customer or someone included in the medical standard. Only bills that continue to be the responsibility of the customer or someone included in the standard are allowed. Expenses (bills or receipts) that will be covered by the medical card or by other health coverage are not allowed.
  • Cost sharing amount(s) incurred by persons receiving Community Care Program (CCP) Services from DoA.  See PM 20-28-02 for a description of in-home care services.
  • 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 customer provides his or her 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 Nursing Home Credit cases, do not allow over-the-counter drugs or items ordered by a physician.

  • For NH or SLF cases, charges at the private pay rate can only be applied to the person's credit or spenddown for the month the services are provided and only if the bill has been paid by the customer or the customer remains responsible for the cost. When facility charges are the client's responsibilty, do not authorize payment of LTC services for the same period. LTC costs during a penalty period or for services provided by a terminated, barred or suspended facility cannot be used toward meeting spenddown. Contact the HFS Bureau of Comprehensive Health Services with questions about ineligible providers. 
  • For LTC cases, only allow bills or receipts for medical expenses that are verified as being medically necessary and that were incurred no more than 6 months prior to application and that are for a specific amount. Medically necessary means the medical service or item is administered, provided, or prescribed by a professional medical provider.


1. Do not allow routine and preventive dental services for regular medical customers 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 (SLF).

3. After eligibility is determined, the purchase of a funeral or burial contract may not be applied to reduce the group care credit or to meet spenddown. The purchase of the contract is considered an allowable transfer for LTC as long as the customer receives fair market value (FMV) but does not reduce the portion of the customer's resources that were originally determined available to pay for the customer's care.

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.