All Medicaid Programs

Obsolete Policy

 

Obsolete 0811 - 825 Eligibility Payment Errors

Effective date:  October 1, 2010 - July 31, 2011

Previous Policy

1. Section 825 applies to these medical assistance programs:

• Medicaid,

• Refugee Medical Assistance, and

• The Primary Care Network program (PCN).  

2. Section 825 does not apply to UPP or CHIP.

3. Eligibility payment errors include:

• Underpayments and overstatements of liability

• Overpayments and understatements of liability

4. Types of eligibility payment errors:

Each of the types of 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 clients were not approved for medical assistance or ineligible clients were approved for medical assistance.

2. Eligible clients 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 client was eligible.  

3. The liability amount was overstated or understated because the client 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 client was correctly approved for medical assistance with a client 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 client 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 client, then the underpayment or overstated liability is a conditional payment error.

2. If DOH or the eligibility agency decided that the client hadn’t taken all reasonable actions to make a resource available (371-3, 371-9) 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 client 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 DOH or the eligibility agency decided the client hadn't taken all reasonable actions to make the resources available (371-3, 371-9), the overpayment is a conditional payment error.

5. Causes of eligibility payment errors:

Causes are similar for underpayments and overstatements of liability and for overpayments 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 overpayments 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, overpayments and understatements of liability.

6. Sub sections in this section include:

• 825-1 underpayments and overstatements of liability

• 825-2 overpayments and understatements of liability

• 825-3 preparation for  investigation or calculation

• 825-4 referral for investigation or calculation

• 825-5 Calculation of overpayments and understatements of liability

• 825-6 Referral for adjudication

• 825-7  Adjudication, intentional program violation and fraud, collection,  enforcement, bankruptcy, and locate