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Revision 18-4; Effective December 1, 2018
If the recipient is no longer eligible for a Medicaid type program with a co-payment, do not make any retroactive adjustments to allow the full IME amount. The IME deduction stops and payment of any remaining balance is an agreement between the recipient and the IME provider.
In addition, do not retroactively adjust the co-payment amount for an IME deduction if the recipient:
- discharges from the facility;
- no longer receives waiver services; or
- is not responsible for payment of the IME because someone has been paying the bill on the recipient’s behalf.
Recipient Moves from Facility to Community Waiver
When a facility Medicaid recipient moves to the community with waiver Medicaid benefits, continue the approved IME deduction when there is a co-payment amount other than zero.
The IME deduction ceases if there is no co-payment amount for the community waiver program.
Recipient Moves from Community Waiver to Facility
When a Medicaid waiver recipient with an approved IME deduction enters or returns to a Medicaid facility, verify if the recipient has any balance due on the IME allowance. If there is a balance due, approve a co-payment deduction for the remaining balance of the IME. If a Medicaid recipient re-enters a nursing facility and has an outstanding balance due on an IME incurred during a previous facility stay, allow an IME deduction for the remaining balance.
H-2310 IME Budget Adjustments Due to Death
Revision 18-4; Effective December 1, 2018
Do not process IME requests received more than 10 calendar days after a recipient’s date of death. The recipient's authorized representative, family or trustee is responsible for paying the IME provider after the recipient’s death.
Process IME requests received within 10 calendar days of a recipient’s date of death.
If the IME is approved:
- adjust the recipient’s co-payment retroactively to the first month services were provided; and
- notify the recipient’s authorized representative, the nursing facility and the IME provider.
If the IME is not approved:
- document the reason for the denial in TIERS Case Comments and notify the authorized representative and the IME provider of the denial;
- send Form TF0001, Notice of Case Action, to notify the recipient’s authorized representative; and
- send Form H1053-IME, Provider Notice of Incurred Medical Expense, to notify the IME provider.