Patient Liability & Item D Expenses
If you or your loved one receives CHOICES (i.e. Medicaid) benefits in a nursing facility, you are more than likely familiar with the term “patient liability.” This refers to the amount that a CHOICES recipient must contribute to his/her cost of care every month. The amount set by TennCare is reflected in your bill from the facility. Patient liability is calculated according to the individual’s gross income with certain deductions intended to meet the financial needs of both the individual and his or her dependents (if applicable).
All CHOICES recipients are allotted $50.00 out of his/her gross income to be used towards personal and incidental expenses (e.g. toiletries, haircut). Depending on the individual, deductions are also made to cover health insurance premiums, spousal living expenses, special bank fees, and Item D expenses. Of these, Item D deductions tend to be least understood and, therefore, under-utilized by CHOICES recipients. Please note, Item D expenses are not related to Medicare Part D.
Item D expenses are those not covered by TennCare or a third party such as Medicare or private insurance. Most of our clients have insurance (e.g. Medicare Part D, Advantage, or Supplement) that pays primary, followed by Medicaid (reminder: Medicaid is always the payor of last resort). Even so, there is a list of expenses that are not captured by these insurers, and can present added (unnecessary) financial burden. Our goal as Public Benefits Specialists is to relieve clients of exactly this. Therefore, we ask that you notify our office if/when you incur the following out-of-pocket expenses (i.e. Item D deductions), as TennCare is obligated to reduce patient liability accordingly:
• Eyeglasses & related services
• Hearing aids & related services
• Dental services
• Prescription drugs
• Nursing home bed-hold days
• Medical bills generated 3 months prior to the month of Medicaid application
• Any other medical-related, non-covered expense that you suspect may be considered an Item D expense
In order for TennCare to process a request that patient liability be changed, we must submit an Item D request, or rather, verification of the expense. For this reason, we strongly advise our clients to keep records of the above expenses. As our clients' liaison with the State, we coordinate with TennCare representatives to address and respond to the request. We also keep the nursing facility informed of a subject-to-change liability. Our biggest challenge at present is the wait-time for processing Item D requests, upwards of 2-3 months. While we hope to see improvement in response time, we still urge clients to contact us to discuss the option of an Item D request, or any questions related to paying for medical expenses.