Pennsylvania allows medically necessary expenses to be deducted from a MA eligible nursing home resident’s patient pay obligation. “Any medically necessary service” includes a balance due to a NF from a resident prior to the resident becoming eligible for MA, as long as the expense meets certain conditions. The expense is referred to as a Prior Medical Expense (“PME”). The result of an allowable PME is the NF is able to pay down the prior balance and still receive the full MA monthly payment.
Since the inception of managed care, providers have experienced difficulties in obtaining the appropriate treatment of PMEs. The PA Department of Human Services issued the policy clarification below to address the treatment of PMEs. Click here for MA Enrolled NF Facility Policy Clarification for Prior Medical Expenses. In short, if you have unresolved PMEs from the date of the managed care implementation forward, providers can request the PMEs to be appropriately processed. Click here for DHS’ PME Request Form.
The policy states: “NFs must provide all unresolved PME requests, from the date of CHC implementation in their area to current date, to their respective Field Operations Unit by March 31, 2022.” Based on the language in the policy clarification, it appears DHS should allow the submission of PMEs for consideration for any periods after the implementation of managed care for the provider, regardless of whether the PME claim was previously submitted.
