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UPDATED: JUNE 2011

495.2

OTHER ELIGIBILITY REQUIREMENTS RETROACTIVE ELIGIBILITY PERIOD

REIMBURSEMENT OF PAID MEDICAL BILLS

Description: Reimbursement of paid medical expenses may be made to Medicaid recipients or their representatives for covered care and services obtained during the recipients’ retroactive eligibility periods (pre and post -application periods).

Policy: Social services districts must reimburse, at the Medicaid rate, Medicaid eligible individuals or their representative for qualifying medical expenses paid during the three-month retroactive eligibility period.

Direct reimbursement is not limited to the Medicaid rate or fee in instances where agency error or delay caused the recipient or the recipient’s representative to pay for medical services which should have been paid under the Medicaid program.

NOTE: Social Services districts have the option of reimbursing eligible recipients directly or requesting the Department to make payments for expenses that the district has determined to be reimbursable.

References: ADM

10 OHIP/ADM-9

Dept. Regs. 18 NYCRR 360-7.5 (a)

GISs

03 MA/025

03 MA/019

02 MA/033

98 MA/011

95 MA/032

New York State Fiscal Reference Manual, Volume 1 Chapter 7 and Volume 2 Chapter 5

Interpretation: Reimbursement for paid medical expenses is limited to the Medicaid rate, after application of ALL third party reimbursement, unless there was an agency error or delay which caused the recipient or his/her representative to pay for medical services that should have been paid by the Medicaid Program.

Because Family Health Plus benefits do not begin until eligibility is determined AND enrollment in a plan has occurred, there is no reimbursement available under the FHPlus program during the three- month retroactive period. However, individuals who are otherwise eligible under the Medicaid spenddown program during the three- month retroactive period through the date of enrollment in a FHPlus (MRG)