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UPDATED: JANUARY 2012

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OTHER ELIGIBILITY REQUIREMENTS

RECOVERIES

recipient became ineligible is Medicaid correctly paid.

For federally-participating (FP) individuals, when Medicaid has been incorrectly paid because the recipient had excess income and, in the case of SSI-related individuals excess resources, that were not considered in the eligibility determination, the amount of Medicaid incorrectly paid is limited to the amount of the recipient's excess income/resources liability. The overpayment is restricted to the amount of the spenddown liability. In any event recovery cannot exceed the amount that Medicaid paid.

The overpayment for federally non-participating (FNP) individuals is the total amount of Medicaid payments (fee-for-service or Managed care premiums) expended. The overpayment for Family Health Plus recipients is the total amount of premiums paid during the period of ineligibility.

When Medicaid is provided to a person with a legally responsible relative (LRR) who refuses or fails to make his/her income available to the A/R, an implied contract is created with the non-contributing LRR. The LRR may be responsible for Medicaid paid. Recovery for Medicaid paid may be pursued through court action. The LRR can be offered the opportunity to voluntarily reimburse the district before a court action is initiated. By clearly explaining the district's procedures, a court action may be avoided.

NOTE: Recoveries are not pursued from the parents of: children participating in one of the home and community-based waiver programs; pregnant minors; certified blind or certified disabled children who are 18 years of age or older; children under age 18 who are expected to be living separately from their parents’ household for at least 30 days; and from the parents of a disabled child for Medicaid furnished for school-based medical care and services provided to such child under the IDEA as part of a free and appropriate education.

If a district has a legal basis for making a Medicaid recovery from a recipient of his or her estate, it may commence a court action pursuant to the Debtor and Creditor Law to undo transfers of assets by the recipient and have those assets returned to the recipient or his/her estate so that sufficient assets will be available to satisfy the district’s claim. The Debtor and Creditor Law cannot be used to attempt to have assets returned to a Medicaid recipient for the purpose of making the recipient ineligible for Medicaid prospectively.

MRG