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Effective: December 1, 2006 |
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29.05.30ar1 - IEVS Overpayment Process (Archive) |
Archived: January 1, 2007 |
DHS must track and quantify payments made on behalf of ineligible clients, for all periods of ineligibility, including prior eligibility periods. An overpayment for health care purposes is defined as coverage received that exceeds the amount for which the client was eligible.
Information from an IEVS match which results in ineligibility or adverse changes in past and/or current months necessitates the calculation of an MA overpayment.
Determining the Amount of the MA Overpayment.
Determining the Amount of the MA Overpayment
Follow these steps when there has been a past period of ineligibility due to an IEVS match:
1. Request a Claims History Profile by either:
l Submitting a Claims History Profile (DHS-2133) for the period of ineligibility.
l Contacting your county’s Program Integrity Network (PIN) user.
The claims history will list the amounts that the State has paid for medical services, showing either one or both of the following:
l Payments to medical providers for fee-for-service clients.
l Payments to managed health care plans for client participating in managed care.
2. Upon receipt of the Claims History information, determine the amount of the overpayment for the ineligibility period.
For clients whose re-determination results in:
l A spenddown. The amount of the overpayment for each eligibility period is whichever is less of the following:
n The spenddown amount minus any co-payments, out of pocket medical expenses, and/or medical expenses not used to meet a prior spenddown.
n The total amount of the capitation payment.
l An increased spenddown. The amount of the overpayment is the increased spenddown amount minus the original spenddown amount.
n Deduct from the difference of the spenddown amounts any co-payments, out-of-pocket medical expenses or medical expenses not used to meet a prior spenddown.
n If no claims were paid during this period there is no overpayment.
l An increased MA-EPD Premium. The overpayment amount is the increased premium minus the original premium amount.
l Ineligibility based on a reason other than spenddown or MA-EPD premium.
n If the client participates in managed care, the overpayment amount is the capitation payment for each month of ineligibility, regardless if services have been received.
n If the client uses fee-for-service the overpayment amount is the amount of medical expenses paid for each month of ineligibility.
3. For clients with an overpayment, send the Notice of Medical Assistance Overpayment (DHS-4600) which requests repayment of the overpayment.
Keep a copy of the notice in the case file and send or fax a copy to:
HCEA – IEVS
P.O. Box 64989
St. Paul, MN 55164-0989
Fax – (651) 431-7446
4. If fraud is suspected follow your county’s fraud procedures.
5. Case note overpayment information.
Forward all voluntary repayments to your county fiscal department for receipt along with the Notice of Medical Assistance Overpayment (DHS-4600). Case note the receipt of the repayment.
The fiscal department will process the repayments in the same manner your county processes other recoveries, such as estate recoveries.
The fiscal department should code this recovery as Type IV – Ineligibility – Voluntary Repayment.
Example:
Jim is disabled and receives MA via fee-for-service. He has been eligible for MA services from January of last year. This month his worker receives an IEVS match indicating he has an asset valued at $25,000 that was never reported.
Action:
The worker sends an IEVS Difference Notice requesting verification of the asset.
Jim returns the asset information. He does indeed have an available asset valued at $25,000 that he forgot to report at his initial application and all renewals since.
Action:
Jim was not eligible for MA since his application for this month or future months because he is over the MA asset limit. His overpayment will be based on the medical services paid for by MA.
l Send Jim a closure notice and inform Jim that he must reduce assets before the date of closure.
l Calculate the IEVS Overpayment for all ineligible past and current months based on the amount of claims paid during this time period.
l Send Jim the Notice of Medical Assistance Overpayment (DHS-4600).
Example:
Condolesa has been enrolled in MA since January 2005. She has been on a managed care health plan the entire time. An IEVS match is received in September 2005 indicating that Condolesa has stocks valued at $17,000 which she never reported.
Action:
The worker sends an IEVS Difference Notice requesting verification of the asset.
Condolesa provides verification that she owned the stocks valued at $17,000. She stated she forgot to report the stocks when she first applied and lost the stocks on June 25, 2005 when the company went bankrupt.
Action:
Condolesa was not eligible for MA from January 2005 through June 2005 due to excess assets. She continues to have MA eligibility from July through the current month.
l Calculate the overpayment amount based on the managed care capitation payments from January through June.
l Send Condolesa the Notice of Medical Assistance Overpayment (DHS-4600).
Example:
Mae is 73 years old and has been enrolled in MA since June 2005 without a spenddown. She is receiving services through a managed care health plan. She receives RSDI and has a $1300 asset total. An IEVS match is produced in October 2005 indicating Mae received a $4000 lump sum in July 2005 which she didn’t report.
Action:
Send the IEVS Difference Notice to Mae.
Mae returns the IEVS Difference Notice promptly with verification of the lump sum. She also indicates she forgot to report the income because she used the entire amount to purchase her first car.
Action:
Redetermine eligibility for July based on receipt of the lump sum. Mae now has a spenddown for the certification period that included July but remains asset eligible because she purchased an excluded asset with the funds. Request a Claims History Profile (DHS-2133) for July.
The Claims History Profile is returned indicating a capitation payment of $270. Mae’s spenddown amount was determined to be $2893 for the certification period. She had copayments equal to $100, a $100 deductible and a $500 medical bill that was not used to meet a spenddown.
Action:
Mae’s spenddown amount would have been $2193, the spenddown minus copayments, deductibles and medical expenses not used to meet a prior spenddown. Mae’s overpayment amount is $270, the lesser of the capitation payment and the spenddown minus medical expenses not used to meet a previous spenddown. Send Mae the Notice of Medical Assistance Overpayment (DHS-4600).
Example:
Joel is 19 years old and living on his own. He has been working full-time since November 2005. Joel has been enrolled in MA with a $100 six-month spenddown since October 2005. He is not enrolled in managed care. In January 2006 an IEVS match is received indicating Joel had income in October 2005.
Action:
Send the IEVS Difference Notice to Joel.
Joel provides proof of the income from a temporary job he forgot to report. After eligibility is re-determined based on the unreported income, Joel now has a $500 six-month spenddown. He has no out-of-pocket medical expenses to meet the increased spenddown.
Action:
Request a Claims History Profile (DHS-2133) for October.
The Claims History Profile is returned indicating MA paid for $2000 of medical expenses in October.
Action:
Because Joel received services in October, his overpayment amount is the difference between the new spenddown and the original spenddown: $400. Send Joel the Notice of Medical Assistance Overpayment (DHS-4600).
Ewan is disabled and employed. He has been enrolled in MA-EPD since August 2005 with a monthly premium of $50. In September 2005 an IEVS match is received showing Ewan had unreported income in August and September.
Action:
Send the IEVS Difference Notice to Ewan.
Ewan sends in verification of a second job which ended in September.
Action:
Redetermine Ewan’s higher MA-EPD premium. The overpayment amount is the difference between the new higher premium and the old premium for August and September. Send Ewan the Notice of Medical Assistance Overpayment (DHS-4600).