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If a change results in a decrease in the monthly copay limit, the decrease should be effective during the month in which the change occurred or, if the change was reported untimely (more than ten days after the change occurred), the month in which the change was reported, whichever is later. 21.11.5 Meeting the Copay Limit Members are notified once they have incurred enough copays before the end of the month to meet their monthly copay limit. This notification is informational only and members may not appeal the date the copay limit was determined to have been met. Once the copay is met for a given month, it can never become “unmet” in the same month and the member will not be charged any more copays in that month. Example 13: Tamika is enrolled in HCBW and has a copay limit of $26 for the month of August. On August 12, interChange notifies CARES that Tamika has met her copay limit of $26. CARES issues Tamika an automated notice stating that her $26 copay limit has been met for the month of August and that she will have no copays for the remainder of the month. On August 21, Tamika has a doctor’s appointment. She will have no copay for the doctor’s appointment since her copay limit has already been met for the month of August. On September 1, Tamika will be responsible for copays incurred until her monthly limit is met.

This page last updated in Release Number: 24-02 Release Date: 08/22/2024 Effective Date: 01/01/2024 22.1 Estate Recovery 22.1.1 Estate Recovery Program Definition The state seeks repayment of certain correctly paid health and LTC benefits by Medicaid members through all of the following: • Liens against a home • Claims against estates • Affidavits • Voluntary recoveries 22.1.2 Recoverable Services Not all services provided by Medicaid are recoverable. Recoverability depends on what was provided and the member’s age and residence when he or she received the benefit. The following are the services for which ERP may seek recovery: 1. All Medicaid services received while living in a nursing home on or after October 1, 1991. 2. All Medicaid services received while institutionalized in an inpatient hospital on or after July 1, 1995. 3. Home health care services received by members age 55 or older on or after July 1, 1995, consisting of: a. Skilled nursing services. b. Home health aide services. c. Home health therapy and speech pathology services.