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  Medicaid Policy                                                                 

 

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825 Eligibility Payment Errors

Effective Date: April 1, 2019

Previous Policy

 

  1. Section 825 applies to these medical assistance programs:
  1. Section 825 does not apply to UPP or CHIP.
  2. Eligibility payment errors include:
  1. Types of eligibility payment errors:

Each of the eligibility payment errors can be either an underpayment or overstatement of liability or an overpayment or understatement of liability.

    1. Eligibility error:  A mistake in the eligibility determination:
      1. Eligible members were not approved for medical assistance or ineligible individuals were approved for medical assistance.
      2. Eligible members were approved for a medical assistance program or eligibility coverage group with a scope of services more extensive or more limited than the program or coverage group for which the member was eligible.
      3. The liability amount was overstated or understated because the member was incorrectly approved for an eligibility coverage group and had a larger or smaller liability calculated than required by the correct eligibility coverage group.
    2. Liability calculation error: The member was correctly approved for medical assistance with a member liability but the amount of the liability was higher or lower than it should have been.
    3. Conditional payment error:
      1. A conditional underpayment or overstated liability error:
        1. If a member chose not to receive medical assistance pending the fair hearing decision or the SSA appeal and the fair hearing decision or SSA decision supported the member, then the underpayment or overstated liability is a conditional payment error.
        2. If DHHS or the eligibility agency decided that the member hadn’t taken all reasonable actions to make a resource available (575-3, 463-3) but the agency or fair hearing decision reversed that decision, then the underpayment is a conditional payment error.  
      2. A conditional overpayment or understated liability error:
        1. If a member chose to receive medical assistance pending the fair hearing decision (125-3) or the SSA appeal (303-7) but the fair hearing decision or the SSA appeal supported the agency, then the overpayment or understated liability is a conditional payment error.
        2. If DHHS or the eligibility agency decided the member hadn't taken all reasonable actions to make the resources available (575-3, 463-3), the overpayment is a conditional payment error.
  2. Causes of eligibility payment errors:

Causes are similar for underpayments and overstatements of liability and for over payments and understatements of liability.  There are some differences:

    1. Only agency errors and inadvertent household errors cause underpayments and overstatements of liability.   Agency errors, inadvertent household errors, suspected intentional program violations, intentional program violations, and fraud are causes of over payments and understatements of liability.
    2. The same inadvertent household error, such as unintentionally failing to report changes in household circumstances, could result in an overpayment or an underpayment, depending on the information that was not reported.

To clarify these differences, the causes are described in subsection 825-1, underpayments and overstatements of liability and in subsection 825-2, over payments and understatements of liability.

  1. Cooperate in Quality Reviews

Underpayments and over payments may be discovered during quality reviews that the Department or the eligibility agency conducts.  Applicants and recipients are required to cooperate with the Department and the eligibility agency in quality reviews.  See 107-7.

  1. Sub sections in this section include: