Medicaid Policy
Medicaid Policy
No Previous Policy
Retroactive period and month of application
When the eligibility agency receives information about the member’s circumstances that indicates the initial determination or retroactive determination was incorrect, the agency must use that information to determine the correct initial and retroactive eligibility and member liability. The benefit effective dates for the month of application and the retroactive period (711) apply.
The 10-10-notice rules (815) do not apply to the correction of initial and retroactive eligibility.
Inadvertent household errors resulting from conditional payments (825, #4C)
When the fair hearing or the SSA appeal supports the agency or when the eligibility agency decides that the member hasn’t taken all reasonable actions to make the resource available, the payments for the medical services the member received are the overpayment.
When the fair hearing supports the agency’s decision that the member’s liability was higher than the member paid while waiting for the hearing decision, the difference between the correct liability amount and the amount the member paid is the understated liability amount.
Months after the application month and the 10-10-notice rules
When the eligibility agency receives information that indicates the eligibility or member liability is incorrect, use the 10-10-notice rules to decide the earliest month the correct eligibility or liability could have been issued.
Members must report changes within 10 days of the date they learn of the change (815).
If the member reported the change within 10 days of the date the member learned of the change, use the actual date of report.
If the member didn’t report the change, use the date of the change to determine the 10 day reporting period.
The eligibility agency must act on the report within 10 calendar days of the day it receives the report.
If the member reported the change, the 10 days for agency action starts on the date of the report.
If the member did not report the change, the 10 days starts on the 10th day from the date of the change.
If the member reported but the agency did not act on the report within 10 days of receipt, use the 10 days from the date of receipt of the report to determine when the agency should have acted.
If the change results in a closure, a reduction in benefits, or an increased liability, the eligibility agency must issue advance notice.
For most closures, reductions or increases in liability, the agency must issue advance notice at least 10 days before the effective date of the change in eligibility or member liability (811).
Section 811 describes exceptions to the 10 day advance notice rule. The agency must issue the notice no later than the effective date of the change for these situations.
If the agency suspects an intentional program violation (811), the agency must issue a notice at least 5 days before the effective date of the change.
The beginning month for the calculation of the overpayment or understatement of liability starts with the month that follows the end of the notice period.