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UPDATED: JUNE 2011
495.4
OTHER ELIGIBILITY REQUIREMENTS RETROACTIVE ELIGIBILITY PERIOD
REIMBURSEMENT OF PAID MEDICAL BILLS
• incurred beginning 45 days after the date of application and before the receipt of a CBIC card; or • incurred beginning 30 days after the date of application when the application includes a pregnant woman or child under the age of 19 and before the receipt of a CBIC card; or • incurred beginning 90 days after the date of application when the application is based on disability and before receipt of a CBIC card; and • medically necessary; • covered by the Medicaid Program ; • within Medicaid requirements for amount duration and scope; and, • received from providers lawfully permitted under State law or regulation to provide the care, services or supplies for which the recipient is requesting reimbursement and who has not be excluded by the Medicaid Program.
FHPlus: After eligibility for FHPlus has been determined, the agency must process the plan enrollment by the 45th day following the eligibility decision if the decision was timely. If the decision was made after the proper timeframe, the agency must process the plan enrollment by the 45th day following the day the decision should have been made. When enrollment does not occur within these timeframes, the applicant is entitled to be reimbursed for reasonable out-of-pocket expenses paid from day 45 to the date enrollment is actually effective.
Agency Error:
Reimbursement may be made to a Medicaid eligible individual or his/her representative for bills that are paid as a result of an LDSS’s error and are: • incurred from the date of the social services district’s incorrect determination until the date the applicant receives a CBIC card; • medically necessary; • covered by the Medicaid Program; • within Medicaid requirements for amount duration and scope; and, • received from providers lawfully permitted under State law or regulation to provide the care, services or supplies for which the recipient is requesting reimbursement and who has not been excluded by the Medicaid Program.
(MRG)