Support Guidelines and Unreimbursed Medical Expenses
The Pennsylvania Support Guidelines contain provisions with regard to payment of unreimbursed medical expenses when parties have a support order through their local domestic relations office. The procedure for reimbursement of unreimbursed medical expenses by the party not receiving support can vary from county to county in Pennsylvania and for many, the process can be confusing.
In Lancaster County, all support orders contain a provision that the individual receiving support is responsible for the first $250 of any out-of-pocket medical expenses before the individual paying support has any obligation to contribute to unreimbursed medical expenses. This $250 amount is often referred to as “the cash medical deductible.” If you are receiving support and you have incurred an out-of-pocket medical expense, what should you do? First, have you paid $250 out-of-pocket? All expenses must be submitted to the insurance provider and only what is not covered by the insurance provider is considered out-of-pocket. You must pay $250 in a calendar year to meet the threshold. Then you are able to request reimbursement of the amounts that exceed $250.
Requests for reimbursement are best made on a quarterly, biannual or annual basis. Submitting requests every time a bill is received can create an unnecessary hassle. Typically, I advise clients to keep track of all of the unreimbursed medical expenses that exceed the $250 deductible and request reimbursement from the other party on a schedule that works for your financial circumstances. The request must be made in writing with proof that you have paid $250 out-of-pocket, include the amount that has been incurred and paid above the $250 amount and then include the calculation of what the other party owes according to the terms of your support order. For example, your support order would say Payor (the person paying the support) is responsible for 53% of all unreimbursed medical expenses and Payee (the person receiving the support) is responsible for 47% of all unreimbursed medical expenses. Those percentages are then applied to the unreimbursed medical expenses above $250 to determine the amount which should be reimbursed to you.
Once the information is provided to the other party for payment and if payment is not received within a reasonable period of time (typically 10-30 days), then you are entitled to seek a medical enforcement conference through the Lancaster County Domestic Relations Office. That conference is solely limited to the issue of unreimbursed medical expenses. To get a conference scheduled, you must fill out specific forms listing each medical expense, when it was submitted to the insurance provider, whether or not it was reimbursed, and if not, when you paid the expense, along with verification that you provided the expense information to the other party in writing so that they had an opportunity to pay it before you sought enforcement through Domestic Relations. The Domestic Relations office will schedule a medical enforcement conference attended by both parties and a conference officer who assists with determining each party’s responsibility for payment of the expenses.
Don’t forget that unreimbursed medical expenses typically include not only medical expenses, but also dental, orthodontia and vision expenses. Reasonable counseling expenses can be included if they are court ordered or agreed upon between the parties. Cosmetic procedures such as plastic surgery, teeth whitening, and the like are not considered reasonable medical expenses. It is also important to remember that reimbursement for medical expenses by the other party must be requested no later than March 31 of the year following the year in which the medical expenses have been incurred or a party loses the right to request reimbursement.
Reimbursement of medical expenses can be a timely and confusing process, particularly when there are expenses for multiple children. The $250 deductible not only runs on a calendar year, but also is particular to each person. So if you have three children, you must incur $250 per child before you can request reimbursement of expenses for that particular child. It is not a cumulative deductible and you are not precluded from requesting reimbursement for one child when the other children have not reached the $250 deductible.
It is important to organize records relating to expenses that are incurred so that you have proof of the expense, the submission to insurance, the amount that is unreimbursed, and what is paid. This information should be provided with your request for reimbursement and is also required should enforcement through Domestic Relations be necessary. I typically advise clients to keep a folder for each individual and to put all records related to that individual’s expenses in their folder. In addition, many insurance companies provide online access which provides digital copies of Explanation of Benefit (EOB) worksheets detailing payments and out-of-pocket costs.
If you find the process overwhelming and have concerns about filling out the Domestic Relations paperwork correctly, the attorneys and paralegals at Russell, Krafft & Gruber have significant experience in dealing with unreimbursed medical expenses and the process of obtaining reimbursement. If you are the party responsible for paying unreimbursed medical expenses, we are also happy to help you with ensuring that the amount you are being requested to pay is the correct amount and ensuring that the other party has followed the required process correctly before requesting payment.
Holly Filius is an attorney at Russell, Krafft & Gruber, LLP in Lancaster, Pennsylvania. She received her law degree from Widener University School of Law and practices in a variety of areas, including Family Law.