Page 207

(MRG)

UPDATED: NOVEMBER 2009

304

INCOME EXCESS

PAY-IN

NOTE: Once the individual has paid in the amount of his/her excess income to the local social services district, s/he is treated like any other Medicaid recipient. Thus, the recipient must receive services from Medicaid providers in order for Medicaid payment to be made. Expenses paid or incurred from non-participating providers will not provide credit or refunds for covered services rendered to the recipient.

The local district establishes a special account to safeguard the funds paid by the individuals. Such amounts are not retained in interest-bearing accounts.

Local districts periodically reconcile the amount in the Medicaid recipient’s account with the amount of Medicaid payments made on the recipient’s behalf. The amount in the account is compared to the Medicaid payments made for services provided during the covered period. Any unused pay-in amounts are refunded to the recipient or credited to a subsequent excess income period.

NOTE: When reconciling the individual’s Pay-In account, local districts take into consideration any off-line payments made on behalf of a participant, since these payments will not be reflected in the Adjudicated Claims history report.

Verification: Expenses for outpatient medical care, including prosthetic appliances, may be verified by:

(1) Seeing medical bills;

(2) Seeing cancelled checks or receipts;

(3) Seeing Medicare or insurance explanation of benefits;

(4) Clearing with the medical provider.

Documentation: Sufficient to establish an audit trail:

(1) Date and type of services, amount of charge and name of provider; and (2) If a third party insurer is involved, the amount of the third party payment or the denial of benefits and the net amount of the A/R’s responsibility.