The Basics of Other Medical Expenses (OMEs)

What is an OME?

An OME is an unpaid medical bill with a service date prior to the Medical Assistance (or Medicaid) effective date. These bills can be submitted to the Nursing Home as deductions from the total amount owed by the resident as their patient pay liability (income minus certain deductions), however they cannot be used as deductions if gifting has occurred.

There is no dollar limit on the total amount of OMEs nor is there a timeframe prior to Medicaid eligibility that the OMEs need to fall within. The only exceptions that disallows OMEs from being deducted from the Nursing Home costs are if long term care expenses incurred six months or more prior to Medicaid eligibility or if long term care expenses incurred as a result of an imposed penalty due to gifting.

What to do with an unpaid medical bill that should be deducted from the Nursing Home Bill:

As medical bills are obtained, take note of the date of service (not the date of the bill). If the date of the service is after the Medicaid eligibility date, it is covered by Medicaid. (NOTE: Many times emergency medical services (EMS) such as ambulance costs will not be covered by Medicaid and therefore are OMEs no matter when the date of service). If the date of service is prior to Medicaid eligibility it can be submitted to the Nursing Home as an OME. First thing to do is run the bill by the Business Office at the Home to verify that the bill should be paid at all. If so, hold making the payment until Medicaid is approved. Our office would advise that you contact the billing department of the bill location, however, and let them know that you are applying for Medicaid and they should make a note on the account to not send the bill to collections during the Medicaid application process (which can take a few months). After Medicaid approval, contact all locations of medical bills and provide the Medicaid claim number so the bill can be reprocessed under Medicaid. Any bills which are not covered (due to falling before the Medicaid eligibility date) should be paid with the request that the billing department send you a $0 balance invoice (showing the bill was paid). You may then submit these $0 balance bills to the Nursing Home as OME deductions to get to a total patient pay liability amount.

Pushback from Nursing Homes on OMEs:

In many cases, staff at Nursing Homes are not educated on all of the complex laws surrounding Medicaid. It is not uncommon for staff at a Nursing Home to either never have heard of an OME or to refuse to accept $0 balance bills as OMEs for dates prior to Medicaid eligibility. If you run into either kind of pushback from the Nursing Home, you may cite the part of the law which states what is deductible as an OME 55 Pa. Code Section 181.452(d)(5). If you continue to receive pushback from the Home, you may call our office however you may be subject to additional legal service fees.