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COMAR 10.09.24.15

1503

State of Maryland Medical Assistance Manual Revised July 2012 A court order permitting recovery may exist because of a determination that the Program has paid benefits on behalf of a person that should not have been paid or would have been paid in a lesser amount had the A/R or representative accurately provided required information and reported changes in a timely manner.

It is the responsibility of the LDSS to report any incident in which income, resources or other factors that could affect eligibility have been: unreported, reported in an untimely manner, or Erroneously reported.

The LDSS must report such incidents on the DHMH 4243, Referral for Investigation. The DHMH Office of the Inspector General (OIG) will decide what action is appropriate based on its findings. Criminal or Civil action may be indicated, or an agreement may be reached between the Department and the recipient for reimbursement of incorrectly paid funds. The OIG may also decide that no action is warranted. However, prompt reporting on the DHMH 4243, and clear, accurate, complete case records are essential for the effectiveness of recoveries by the OIG.

The LDSS should also report any suspected provider fraud or abuse, or recipient abuse of the card to OIG for appropriate action. These may be reported by telephone call or memo to the OIG.

1500.3 Benefits Paid Pending Appeal Decision

Regulations require that each case of a person receiving extended benefits pending a hearing decision be referred to the MACA Division of Recoveries via form DHMH 1169 if the hearing officer upholds the decision of the LDSS.

The Division of Recoveries will initiate steps to recover the cost of expenditures made on behalf of the recipient during the appeal process. Exempt from this provision is a person who requests a hearing with a bona fide belief that the LDSS‟ action to cancel Medical Assistance benefits was incorrectly based; for example, on the misapplication of policy, an error in the amount of income and/or resources considered incorrect application of disregards or exclusions, or an otherwise incorrect calculation. The basis for the appeal should be indicated on the DHMH form letter or other written notice requesting appeal.

The Division of Recoveries will decide, on the basis of the stated factors, if the exemption is applicable.

1500.4 Liability

The MA Program will obtain reimbursement in any case in which a MA recipient has a cause of action against another party if the Program has paid out benefits for medical care