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UPDATED: JUNE 2011

495.5

OTHER ELIGIBILITY REQUIREMENTS RETROACTIVE ELIGIBILITY PERIOD

REIMBURSEMENT OF PAID MEDICAL BILLS

NOTE: Reimbursement may also be available when, due to social services district delay in the provision of authorized services such as personal care services, the recipient or the recipient’s representative must pay privately to obtain covered services.

FHPlus: For individuals determined eligible for FHPlus, such recipient or his/her representative may be reimbursed for reasonable out-of- pocket expenses (as defined below) paid after the date of the agency’s error (as found on the Notice of Decision) through the day the individual’s FHPlus enrollment is effective. The services must be those that are covered under the FHPlus plan and must be provided by an entity or individual lawfully permitted to provide the care, services or supplies for which the recipient is requesting reimbursement.

Reimbursement in cases of agency error or delay must be made for reasonable out-of-pocket expenditures. Generally, out-of-pocket expenditures that do not exceed 110% of the Medicaid rate are always considered reasonable and may be fully reimbursed. In some instances out-of-pocket expenses that exceed this threshold may be considered reasonable if the recipient or his/her representative can demonstrate and document that the services cost more due to living in a remote location or purchasing services on a holiday or other special circumstance. In such situations, reimbursement of full-out-of pocket expenses may be warranted.

To obtain reimbursement for bills paid during the retroactive periods, the recipient must document income and resources, as appropriate, in order for eligibility to be determined for the appropriate retroactive period. In all circumstances, proof that the bills for which direct reimbursement is sought were paid must be provided. Claims not supported by proof of payment with documentation such as cancelled checks or notarized affidavits are not reimbursable.

NOTE: Once a CBIC card is received, NO reimbursement may be made for expenses incurred after that date and paid by a recipient.

Social services districts must provide information concerning the policy for direct reimbursement of medical expenses to all Medicaid/FHPlus applicants, including those who apply at outreach sites and to all Temporary Assistance applicants who also apply for Medicaid. The provision of the LDSS-4148B: “What You Should Know About Social Services Programs” to such applicants fulfills this requirement.

(MRG)