Medicaid Policy
Medicaid Policy
No previous policy
A. Time Limit to Make Payments
Members who must pay a spenddown, MWI premium or waiver cost of care to DWS are required to meet their payment before receiving Medicaid benefits.
Applicants
1. Applicants must meet their payment by the close of business on the business day that is 30 days from the mailing date of the notice informing the member of their payment amount owed. For someone applying on the basis of blindness or disability, the payment must be met on the business day that is 30 days from the mailing date on the payment notice, or by the end of the 90-day application-processing period, whichever is longer. See Sec. 703-5
a. The payment due date applies to meeting the payment for any months, or partial months of coverage in the retroactive period for which the member requests coverage.
b. Members cannot pay a spenddown, MWI premium or cost-of-care payment more than 10 days before the first day of the benefit month for which they want coverage.
c. If the 30th day is a non-business day, the member has until the close of business on the first business day after the 30th day to meet the payment.
d. Subject to the following policy in this section, if the member does not meet the payment by the due date, deny or close the Medicaid.
Recipients
1. Recipients must meet their payment for ongoing months by the close of business on a business day that is one of the following dates:
· 30 days after the mailing date of the notice informing the member of their payment, OR
· The 10th day of the month following the benefit month for which the member wants coverage, whichever is longer.
· If the due date is a non-business day, the member has until the close of business on the first business day after the due date to meet the payment.
2. If the member meets the current month's payment, but not the previous month's, keep the program open unless the member asks for it to be closed.
3. Any time the member has not met their payment for two consecutive months, i.e., the previous month and the current month, close the program at the end of the month for which we can send ten-day notice of closure.
· If the member is Medicare eligible, review eligibility for the Qualifying Individuals program if you are closing Medicaid. If eligible, extend eligibility back to cover months in which the member did not meet spenddown. This may include more than the 3 prior months if the member has not met spenddown in such months.
· Continue the SLMB coverage for an eligible individual who chooses not to meet their payment.
· If the member meets the spenddown for the current month after setting the program to close, revert the program to open. Continue eligibility into the following month to see if the member wants to meet the spenddown.
Returning checks or money orders
1. If a member sends a check or money order on time to meet the payment, but either the amount is wrong or they do not indicate which month's payment they want to meet, the Business Office must take the following actions:
a. If the member has not clearly indicated what month (or months) they want Medicaid, call the member and ask what months they are trying to meet the payment before applying the payment.
b. If unable to reach the member by phone, return the check or money order to the member following proper Business Office financial procedures. Include a notice explaining why the check is being returned. The notice must provide clear directions and a due date for the member to resend the payment with the correct amount and a clear indication of what month, or months, the member wants Medicaid.
2. If the member has sent proof of medical bills but not indicated which month they want coverage, the agency needs to call the member or send a notice explaining we cannot apply medical bills until the member says which months they want to meet the spenddown, or cost-of-care contribution.
· If the amount of allowable medical expenses provided does not cover the spenddown for all the months the member indicates, follow-up with the member to see what months they want to use the expenses.
3. If a payment is received late, see C. below.
B. Coverage in the Retroactive Period
1. Sometimes an applicant may not request coverage for the retroactive period when he or she first applies. The member may later ask for coverage for any of the retroactive months associated with an approved application. Refer to Sec. 705-3 for policy on retroactive coverage.
· If determined eligible for a retroactive month, this would be a new decision. In this case, the member has 30 days from the mailing date of the approval notice to meet spenddown, MWI premium or waiver cost-of-care for the months of retroactive coverage the member wants.
· If the 30th day is a non-business day, the member has until the first business day following the 30th day to meet the payment.
2. Providers are not required to accept Medicaid for past months. If a member must pay a spenddown or premium, the member should find out if the providers will accept Medicaid coverage and bill Medicaid for services received in the past months.
· If any of the dates of services received during the retroactive period for which the member wants coverage are more than 12 months ago, the system automatically denies them. Refer to 705 for more information on how providers may be able to resubmit claims that are over 12 months old. [NOTE: This sometimes occurs when a member's disability decision is approved more than 12 months after the application date.]
C. Member Fails to Meet Payment on Time
If a member does not meet the payment by the due date, the member can reapply for coverage for the months in question. Those months must be within the retroactive period of the new request date or new application. A new application may not be needed. Treat receipt of payment like receiving verification. (703-1)
The member would have to meet the new payment, if applicable, as described above for an applicant. (See Sec. 705 to determine the retroactive period.)
When reviewing medically needy eligibility for retroactive months, re-determine income using actual income for such months.
1. Late payment received. If the agency receives a payment after the due date, the payment cannot be applied to meet that prior month's payment. Also, do not apply the payment to a current month without contacting the member for approval. If the month the member wanted to meet the payment is still within one of the 3 previous months (based on the date payment is received), the member may still be able to receive Medicaid for such previous month.
· Try to reach the member by phone to see if the member still wants coverage for the previous month in question. Explain that the payment was late, and the agency must make a new eligibility decision.
· If the member wants coverage for such month, treat the date the eligibility agency received the payment as a new application date. The Business Office staff needs to tell the eligibility worker the member wants coverage for the retroactive month.
· Request any additional information needed to make a new decision. Only request a new application if the agency cannot obtain the information any other way.
· The Eligibility Specialist must make a new determination, and recalculate the payment as a retroactive month (as applicable). Follow policy in 705. Send a new decision notice, which will include a new due date.
· The Business Office will usually have to return the payment. Follow Business Office financial procedures.
Example: Midge owed a $350 spenddown for April. The Business Office received a check on May 16th saying it was for the April spenddown. May 16th is after the due date of May 10th, so cannot be accepted. The Business Office refers the case to the eligibility specialist to redetermine eligibility and spenddown for April. The receipt of payment is like a request for retroactive coverage. The eligibility specialist reviews the case, and requests copies of paystubs for April, to determine the actual income. In the meantime, the Business Office returns the payment to the member according to their procedures. Upon receiving the paystubs for April, the eligibility specialist sends a new notice to the member with the revised spenddown amount, and the new due date to meet spenddown.