Incurred Medical Expenses: Suggested Steps for Dental Professionals

Paying the Nursing Facility's Bill

Upon admission to a nursing facility, a Medicaid Caseworker determines how much income a resident receives each month and applies that income to pay their Nursing Facility's bill, except for an amount for personal needs and certain other required deductions. Generally, residents on Medicaid don't have enough income to pay the total amount of the Nursing Facility's Bill, so the Caseworker notifies Medicaid to pay the remaining balance each month.

Paying the Dental Bill

When a resident receives a Dental Bill for services that are not covered by Medicaid or another third party payer, the bill may qualify as an Incurred Medical Expense. The resident's Medicaid Caseworker plays an important role in this process. He or she would review the Dental Bill, and where appropriate, approve it as an Incurred Medical Expense, and then notify the resident or the resident's financial representative to pay the Dental Bill instead of that portion of the Nursing Facility's bill. At the same time the Caseworker approves payment of the Dental Bill, he or she requests an increase in the amount that Medicaid pays towards the Nursing Facility's bill to make sure that the facility continues to be paid in full. If the total amount of the Dental Bill is less than the resident's total monthly income, then the Dental Bill can be paid in full with just one payment. If the total amount of the Dental Bill is greater than the monthly income, then several monthly payments will need to be approved so that the entire Dental Bill gets paid. During each of those months, the Nursing Facility's payment from Medicaid would be increased in the amount of the Dental Bill payment.

Each state will have variations in the procedures for Incurred Medical Expenses. Work with the resident's Medicaid caseworker to identify and address these variations.

Before Treating a Medicaid Resident

  1. Confirm that the nursing facility resident is currently enrolled in Medicaid. Obtain consent from the resident or the resident's representative for dental examination and for release of necessary medical and financial information needed to provide dental care.
  2. Review the dental benefits that are covered under your state's adult Medicaid program. (You must bill Medicaid directly for covered services). Incurred Medical Expenses applies ONLY to services that are not covered under the state Medicaid program and any other third party payer. Keep in mind that only medically necessary dental services can be paid for through this method.
  3. Check with the resident, his or her financial representative, or Nursing Facility staff to confirm that the resident has applicable income that is currently used to pay for some or all of the monthly Nursing Facility Bill. If the resident doesn't have any income of this type, they will not be able to use this procedure to pay for dental care.
  4. Prior authorization before providing dental services is not required in most states, but check with the nursing facility caseworker and/or state Medicaid agency for specifics regarding your state.

After the Examination

  1. Prepare a treatment plan for the resident and obtain informed consent for dental services from the resident or the responsible party.
  2. Follow your state's requirements and guidelines for services covered under the adult Medicaid program.
  3. If required in your state, obtain prior authorization for non-covered services from the resident's Medicaid Caseworker.
  4. Provide treatment as approved in the treatment plan.

Billing for Services

  1. Create an "Incurred Medical Expense" Dental Bill that provides all the information that your state's Medicaid Caseworkers
    will need to process it for payment.
    • Remember that dental services that are covered by adult Medicaid or other insurance policies do not qualify as Incurred Medical Expenses and must be billed separately.
    • Any services that were covered by Medicaid should either not be included in the Dental Bill, or should be clearly identified as having been billed separately and should not be included in the balance due.
  2. Also note that only medically necessary dental services that are NOT covered by Medicaid or any other third party payer may be included on the Dental Bill. For this reason, it is advisable to include the following language on the Dental Bill when appropriate: "This Dental Bill only includes medically necessary services that are not covered by Medicaid or any other third party payer."
  3. Provide a copy of the Dental Bill for the Medicaid Caseworker. Your staff, as well as nursing facility staff, will benefit from getting to know the Caseworkers and communicating with them regularly.
    • After the Dental Bill has been approved for payment, the Caseworker typically sends a letter to the resident or the resident's financial representative directing him or her to make one or more monthly payments until the Dental Bill is paid in full.
    • During the same month or months when the Dental Bill is being paid, the Caseworker will notify Medicaid to increase its payment towards the Nursing Facility's Bill so that the nursing facility is paid in full.