Allowing Out-of-Pocket Expenses in Waiver Determinations

50.11 – Allowing Out-of-Pocket Expenses in Waiver Determinations (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) Out-of-pocket expenses should be considered in determining if a full or partial waiver is warranted. Out-of- pocket expenses are defined as those medical expenses for which a beneficiary has paid or is responsible to pay incurred for injuries directly related to the accident and that are not covered by insurance (including Medicare), settlement proceeds, or court- awarded damages. A waiver of all or part of the out-of-pocket expenses may be granted only if the following criteria have been met. In determining the amount of out-of-pocket expenses to be waived, each case must be considered on its own merits. The MSP Contractor must not automatically assume that out of pocket expenses should be waived. The following documentation should be considered proper proof of the expenses paid: a) Notarized/sworn statement which attests to the validity of the expenses; b) Canceled checks (which correlate to bills received); c) Receipts for services furnished; and d) Copies of bills demonstrating services furnished. The following are types of out-of-pocket expenses that may support granting a waiver: a) Housing renovation – beneficiary’s residence had to be modified to accommodate beneficiary because of an accident-related injury e.g., addition of a ramp to accommodate a wheelchair; b) Adult diapers - where the accident caused loss of bladder use; c) Prescriptions for medication needed as a result of an accident-related injury; d) Private duty nursing or custodial care not covered by Medicare; e) Coinsurance and deductibles not covered by supplemental insurance; and f) Expenses for dental work caused by the accident. MSP Contractors should not consider: a) Funeral expenses; or b) Travel for relatives (even if accident-related).