When a decision of ineligibility for SSI cash benefits, TANF cash benefits, or MA benefits is reversed or corrected, the recipient may be able to get money for medical expenses from the time covered by the wrong decision. The expenses must have been paid by the recipient or a individual legally responsible for the recipient.
The following are examples of reversed and corrected decisions:
An applicant for SSI cash benefits is turned down for SSI cash benefits by the Social Security Administration (SSA)The applicant appeals the decision, and the SSA reverses it. The applicant is now eligible for MA.
An applicant or recipient is turned down for TANF cash, NMP-MA, or MNO-MA benefits. The decision is reversed after an appeal and fair hearing or after an office error is found by DHS. (Administrative errors include using the wrong category or program status code.)
NOTE: Children under the age of 21 in a GA cash category or GA-related MA category are covered by the rules in this section.
The corrective action periods for payment of an unpaid medical expense and for paying a recipient back for a paid medical expense are as follows:
For applicants—from the date of application through the date of the reversed decision.
For recipients—from the date of the wrong decision through the date of the reversed decision.
NOTE: For the corrective action coverage period for non-SSI applicants, see Section 338.3. For SSI applicants see Section 387.52.
Within ten days of finding out about a reversed or corrected decision, the CAO will send the following forms or notices to let the recipient know of the eligibility and the corrective action coverage period:
To SSI recipients—a PA 162M.
To all other recipients—a written notice.
For All: A [Corrective Action Paid Medical Expense Reporting Form (PA 1646)].
A recipient with an unpaid medical expense in the corrective action coverage period must contact the medical provider to find out if the provider is currently enrolled in the MA program or was enrolled at the time the recipient got the service.
If the medical provider is or was enrolled in the MA Program, the recipient should tell the medical provider that the recipient is eligible for MA. The individual should give the provider written proof of MA eligibility and ask the provider to bill DHS.
If the medical expense is covered by MA, the provider will bill DHS. The recipient does not need to do anything else.
If the medical expense is not covered by MA, the provider should tell the recipient. The recipient must pay the medical expense.
If the medical provider is not or was not enrolled in the MA program, the recipient must pay the provider.
A paid medical expense must have been paid by the recipient or a individual who is legally in charge of the recipient.
A recipient who got and paid for a medical expense in the corrective action coverage period must contact the medical provider to find out if the provider is enrolled in the MA program or was enrolled at the time the recipient got the service.
If the medical provider is not or was not enrolled in the MA Program, DHS will not pay the recipient back.
If the medical provider is or was enrolled in the MA program, the recipient will fill out the Corrective Action Paid Medical Expense
Reporting Form. The recipient will mail the form and other papers to the address on the form within 30 days of getting it.
If the recipient needs another copy of the original Corrective Action Paid Medical Expense Reporting Form, the CAO must provide it upon request.
The Office of Medical Assistance Programs (OMAP) must decide whether an individual is eligible for payment or repayment on the basis of the following:
Provider enrollment.
Medical necessity.
Service eligibility.
Fee schedule levels.
OMAP will not apply earlier conditions for approval for medical expenses from the corrective action period.
When OMAP gets the Corrective Action Paid Medical Expense Reporting Form and papers from the recipient, OMAP must take the following actions:
Determines whether the recipient is eligible for payment or repayment.
Sends a notice about the decision to the recipient and to the recipient’s legal representative, if any.
Sends a copy of the notice about the decision to the CAO.
Sends a request to the Office of the Comptroller so that a check can be issued to pay the recipient back.
Processes the provider’s invoice to pay a provider.
The CAO keeps the copy of OMAP's decision in the recipient’s record so that it can be referred to when looking at the recipient’s MA medical expense deductions.
NOTE: The recipient cannot use a medical expense payment or repayment given under these rules of this chapter as a deduction for future MA eligibility decisions.
If direct payment is made to the recipient, the amount must not be counted as income or a resource.
If a recipient has questions about a OMAP written decision, tell the recipient to call the OIM Helpline at 1-800-692-7462.
The recipient has the right to file an appeal and ask for a fair hearing if he or she still disagrees with OMAP's decision after calling the Helpline.
Updated February 14, 2012, Replacing April 12, 2007