Medicaid Policy
Medicaid Policy
1. An underpayment is a payment for medical services that the agency should have made but didn’t because the member was incorrectly determined to be ineligible.
2. An underpayment also is a payment for medical services that the agency should have made but didn’t because the member was approved for a medical assistance program with a scope of medical services more limited than the program the member was eligible for.
3. Liability is the amount that the member must pay toward the cost of medical care. Liability includes:
A. The spenddown amount (461).
B. The contribution to cost of care for HCB waiver programs (381, 382, 383, 384, 385, 386, 387, 388 and 389)
C. The contribution to cost of care for services provided by nursing homes.
D. The MWI premium (462).
4. An overstated liability occurs when the member pays more than the correct liability amount because the liability amount was calculated incorrectly.
5. An overstated liability also occurs when the member paid the correct spenddown or contribution to cost of care but the medical assistance program paid less for the medical services than the amount of the member’s liability.
6. MWI members who pay a correctly calculated MWI premium do not have an overstated liability when the amount paid for the services the member received was less than the MWI premium. The MWI premium is based on the member’s income and it is similar to an insurance premium. The MWI eligibility is not based on the cost of the member’s medical services.
Members in nursing homes who pay a contribution to cost of care that is more than the correct amount do not have an understated liability error that the Medicaid agency refunds. The nursing home must work with the eligibility agency to adjust the member’s liability amount and to receive the correct payment from the Medicaid agency.