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Medicaid Deductible

What is the Deductible?

The N.C. General Assembly has established income limits, which county departments of social services use in determining eligibility for Medicaid. These limtis are based on the number of persons in a family. If the income of the family is more than the amount set by the General Assembly, there will be a deductible.

Medicaid eligibility is determined for a six-month period. This period is called a certification period. The amount of the deductible is determined by subtracting the monthly income limit from the family's countable monthly income. That amount is multiplied by six. The result is the deductible for the certification period.

The certification period usually begins with the month that you apply for Medicaid. A case with a deductible is not eligiible for Medicaid coverage of medical expenses until the deductible is met.

Whose Income and Medical Bills Count Toward the Deductible?

For married couples, the incomes and medical bills of both are counted. A parent's income and medical bills must be counted for a child.

How do I Meet the Deductible?

A Medicaid deductible is met by adding up medical costs. Payments for medical care, supplies and prescriptions may apply to your deductible. You will be authorized for Medicaid on the date that the bills add up to the amount of the deductible. You will be authorized to receive Medicaid through the end of the 6 month certification period.

Only the portion of the bill that you must pay can be applied to the deductible. You cannot use bills that someone else pays for you or that insurance pays. If insurance pays part of the bill and you pay the rest, only the part that you have to pay is counted.

Medicaid will not pay for medical expenses used to meet the 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.

Medical Bills

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.

Unpaid Medical Bills

An unpaid medical bill may be used to meet your deductible. It must be a Medicaid bill described below in "Current Medical Expenses." In order to use this bill, your worker must verify the following:  

• The bill must be less than 2 years old.
• If the bill is over 2 years old, you must have made a payment on it within the past 2 years.
• The bill must be unpaid and the medical provider is still billing you.
• All medical insurance you had at the time must have been filed and either paid or denied payment for the bill.
• 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.

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

Current Medical Expenses

Current medical expenses that are your responsibility may be used to meet your deductible. They may be either paid or unpaid. Take your bills or receipts to your worker. Always ask the worker to make a copy of your bills so that you can keep the original for your own records.

Medical expenses include the following:

• Hospital charges
• Clinic and laboratory charges
• Visits to the doctor, dentist, or therapist
• Prescription drugs
• "Over-the-counter" drugs such as aspirin, Tylenol, Pepto-Bismol, Benadryl, cold medicines
• Medical supplies such as gauze, bandages, needles for medical injections, absorbent pads for the incontinent, alcohol
• Equipment such as dentures, eyeglasses, hearing aids, walkers, wheelchairs, crutches, braces
• Vitamins or supplements such as Ensure, if prescribed by your doctor
• Transportation to the doctor or hospital

For over-the-counter medicines and supplies, you must have a receipt.

Other

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

Ask your worker about medical expenses not listed.