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Effective: August 1, 2009 |
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29.15ar3 - Overpayments (Archive) |
Archived: June 1, 2011 |
Overpayments occur when enrollees receive more health care benefits than they were entitled to because benefits were determined without complete or accurate information from an applicant or enrollee on eligibility factors such as:
l Income.
l Assets.
l Household composition.
l Residency.
l Other insurance.
l Other factors that affect the benefit level.
Overpayment amounts are based on the amount the health care program paid for benefits on behalf of the enrollee, either through fee-for-service claims or managed care payments made on the enrollee’s behalf, less certain costs paid by the enrollee. The costs are compared to the cost of the benefits the enrollee should have received. The overpayment amount may be reduced or eliminated if the enrollee would have been eligible under a different basis for the same program.
There are several methods for collecting overpayments. See Overpayment Notification and Collection.
When to Determine Overpayments.
How to Determine the Overpayment Amount.
Some Household Members Ineligible.
Eligible for Lesser Benefits or Greater Cost-Sharing.
When to Determine Overpayments
Determine overpayments in these situations:
l An IEVS match results in ineligibility for a past period. See IEVS Overpayment Process.
l In conjunction with pursuit of a fraud conviction or Administrative Disqualification Hearing.
l Other situations in which the agency finds that enrollees received more MHCP benefits than they were entitled to because of late reporting or failure to report or disclose information.
Do not cite overpayments when:
l The overpayment is the result of agency error.
l The applicant or enrollee reported accurate information and eligibility was determined using the most complete information available, but estimated income proved to be less than actual income.
Example:
Bruce applied for GAMC in March. He is employed part time with variable hours. Projected earnings are $300 per pay period based on the employment information and pay stubs he provided. At the time of Bruce’s six-month renewal, recent pay stubs show that he worked more hours than anticipated on two occasions.
Action:
Contact Bruce to determine if he expects the additional hours to continue. Use the information to determine eligibility for the next six-month period. There is no overpayment because Bruce provided complete and accurate information when he applied, and he was not required to report normal fluctuations in hours.
l There is suspected fraud or unreported information that has not yet been verified or confirmed.
Example:
Rose receives MA without a spenddown for herself and her two children, ages six months and 18 months. The six-month-old is eligible as an auto newborn. The fraud investigator reports that Rose’s boyfriend, the adjudicated father of the children, moved into the home shortly after the baby was born and is employed. Rose did not respond to the request to provide verification of earnings and the investigator has not yet been able to obtain the information from the employer.
Action:
Close MA for the 18-month-old child for failure to verify earnings. Do not cite an overpayment at this time because it is not possible to determine if the total income that should have been deemed to the child exceeded the standard of 280% FPG. Redetermine eligibility using the verified income to determine if an overpayment exists if the information becomes available later.
The presence of the boyfriend does not affect eligibility for Rose because his income is not deemed to her. However, she must cooperate in supplying verifications for the 18-month-old’s eligibility. Close her MA with 10-day notice if she fails to provide verification. Do not determine an overpayment.
The six-month-old remains eligible as an auto newborn.
How to Determine the Overpayment Amount
Take the following steps to determine an overpayment amount.
1. Redetermine eligibility as if correct, complete information had been reported timely.
n If information was incorrect or missing at the time of application, redetermine eligibility beginning with the first month of coverage.
Example:
Selmer has been receiving MinnesotaCare as a single adult since March 1. On his February application he reported a part time job at McDonald’s. In July the worker receives verification that he failed to report a second job at Burger King on his application. He has held both jobs since his MinnesotaCare began.
Action:
Redetermine eligibility beginning with March using the new information.
n If incorrect or unreported information occurred while a case was active, redetermine eligibility for the eligibility period in which the change occurred. Apply the change to the first month for which the change could have been made with proper notice had correct information been reported timely if the new information results in reduced benefits or ineligibility.
Example:
Jonah has been receiving MA for himself and his ten-year-old daughter since May. Both have been eligible without a spenddown. The following January, Jonah provides verification that he began working on August 7. He did not report the job.
Action:
Redetermine eligibility for the May-October budget period. Although the new earnings would have resulted in a monthly spenddown starting in September, the six-month income remains below the standard for both Jonah and his daughter. However, both would have spenddowns for the November-April budget period. Neither has medical expenses to meet the spenddown. The first month for which an overpayment exists is November.
2. Consider eligibility for all possible bases of eligibility within the same program. There is no overpayment if eligibility would have existed for MA or GAMC with no spenddown.
Example:
Tina received MA without a spenddown for herself and her son from October through the following August. The fraud investigator verifies that Tina started a job in May which she never reported. The earnings exceeded the income limit for both Tina and her son starting in June. Both were coded as potentially TYMA-eligible.
Action:
Evaluate eligibility for Tina and her son. There is no overpayment because Tina and her son would have been TYMA-eligible during the period of potential overpayment.
3. If Step 2 does not apply, request a Claims History Profile following the instructions in Determining the Amount of the MA Overpayment.
4. Determine whether the overpayment caused any of the following:
n Ineligibility for only some household members.
n Eligibility for lesser benefits or greater cost-sharing, such as
m Higher premiums.
m Spenddown or increased spenddown.
m Fewer covered services.
m Higher co-payments.
Follow the applicable instructions for the appropriate situation and program.
For MinnesotaCare, the overpayment is the full amount of claims paid (capitation payments and any fee-for-service payments made) on the household’s behalf, less premiums paid for the months of ineligibility.
Example:
Kyle received MinnesotaCare as an adult without children from January-August. An investigation disclosed unreported assets of $15,000. Kyle was totally ineligible for MinnesotaCare due to excess assets. He had no basis of eligibility for MA and he would not have been eligible for GAMC due to excess assets.
The Claims History Profile shows that capitation payments of $250 were made for Kyle for each month his case was active. He paid premiums of $15 per month.
Action:
Determine the overpayment of $235 per month ($250 - $15) for eight months, or $1,880.
If Kyle had received benefits through fee-for-service during any months, the overpayment for those months would be the actual amount of paid claims less the premiums he paid.
Example:
Kyle’s coverage was stopped effective June 1 due to nonpayment and reinstated on June 15. He was reenrolled in managed care effective July 1. He received benefits on a fee-for-service basis for June. The Claims History Profile shows payment of $150 for a doctor’s visit in June.
Action:
Determine that the June overpayment is $135 ($150 - $15). This reduces the total overpayment for January-August to $1,780.
For MA and GAMC, the amount of the overpayment for the months of ineligibility is one of the following:
l The amount of capitation payments made for any months the client was enrolled in managed care.
l The amount of paid claims for any benefits the client received benefits through fee-for-service.
Example:
LaTasha has been on fee-for-service MA as a single disabled person since June. On October 5, she reports receipt of a lump sum on September 10. The money she retained from the lump sum results in assets exceeding the $3,000 limit for October. Although her countable assets of $5,000 are less than the MinnesotaCare asset limit, LaTasha is not eligible for MinnesotaCare because she is enrolled in Medicare. She is ineligible for MA for October.
Action:
Advise LaTasha that she needs to properly reduce assets to remain eligible for MA for November. Determine the October overpayment based on the total amount of claims paid in October from the Claims History Profile. There is no overpayment for September because October is the first month to which the change could have applied.
If an MA-EPD enrollee is found to be totally ineligible, deduct any premiums and unearned income obligation of one-half of one percent paid by the enrollee from the total paid claims during the months of ineligibility to determine the overpayment amount.
Note: Providers have up to 12 months to submit claims.
Some Household Members Ineligible
For MinnesotaCare, the overpayment is the amount paid for the ineligible members (capitation payments or fee-for-service claims), less the ineligible members’ portion of premiums paid.
Example:
Myra has been enrolled in MinnesotaCare with her two children for six months. The worker discovers that Myra has had access to ESI for herself only since the time of application. Her income exceeded the limit for eligibility for MA without a spenddown and she has no out-of-pocket or remedial care expenses with which to meet a spenddown. She has been enrolled in managed care for all months.
Action:
Check the claims history. Capitation payments of $250 per month were paid for Myra during the period of ineligibility. Recalculate the premium for the same period for the children only. The household paid $20 additional per month for Myra. The overpayment is the total capitation payments of $1,500 less Myra’s portion of the premium of $120, or $1,380 for the six-month ineligibility period.
For MA and GAMC, the overpayment is the amount of health care services paid for the ineligible members during the months they were ineligible (capitation payments or fee-for-service claims), less any out-of-pocket costs paid by the enrollee.
Example:
The Brady family has been on MA since June 2006. In April 2007, they submit their annual renewal. They report that they sold a previously exempt vehicle in January 2007 and deposited the cash in a savings account. The added cash results in excess assets. The cash would have been counted beginning in February if they had reported the sale of the vehicle within 10 days.
The parents were ineligible for February, March and April. They can remain on MA if they properly reduce their excess assets by May 1.
Action:
The Claims History Profile shows that the family was enrolled in managed care for all three ineligible months. Capitation payments of $200 per month were made for each parent. The overpayment is $1,200 ($400 x 3 months). There is no overpayment for the children because they have no asset limit.
Eligible for Lesser Benefits or Greater Cost-Sharing
For MinnesotaCare, if a change results in continued eligibility for the same benefit set but a higher premium, the overpayment amount is the correct premium less the actual premium paid.
Example:
Harold is active on MinnesotaCare major program FF. His two children are active on major program LL. The worker discovers that Harold got a raise several months ago which he did not report. He and the children all remain eligible for the same benefits.
Action:
Calculate the total premium for the household. It should have increased from $100 to $125 beginning with the first available month after the income change. The overpayment amount is $25 ($125 - $100) for each month.
If a change results in a lesser benefit set for one or more household members, the overpayment is the difference in capitation payments for the two benefit sets.
For MA, follow the instructions for IEVS overpayments in Determining the Amount of the MA Overpayment when the overpayment results in any of the following:
l A spenddown.
l An increased spenddown.
l An increased MA-EPD premium.