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West Virginia Income Maintenance Manual Chapter 10
West Virginia Income Maintenance Manual Page 51 Chapter 10 The Case Maintenance Process
• The client’s coverage is interrupted due to agency delay or error unless the delay is due to factors beyond the control of the DOHS • An application is denied in error • A nursing home contribution is overpaid due to Worker error or failure to act promptly When determining if the client is eligible to receive direct reimbursement for out-of-pocket medical expenses, the Department of Human Services (DOHS) must act on each application or case action within a reasonable period of time unless the delay is due to factors beyond the control of the DOHS. A reasonable period of time must be interpreted on a case-by-case basis. Reimbursement for out-of-pocket medical expenses, including purchases of prescription drugs, is limited to those services covered by Medicaid. The client is reimbursed for the entire sum of his out-of-pocket expenses for those covered services, even if that expenditure exceeds the Medicaid fee schedule in effect at the time the expenditure was incurred. The Community Services Manager (CSM) is responsible for determining if the client is eligible to receive reimbursement for out-of-pocket medical expenses. If it is determined that the client is eligible to receive reimbursement, the CSM must submit a memorandum to the Bureau for Medical Services (BMS) Policy Unit requesting reimbursement, along with the original invoices for the medical expenses for which reimbursement is requested. The memorandum must contain the amount of the reimbursement that is due the client and the accompanying bills must be marked or highlighted to indicate if they are used for reimbursement. When the request for reimbursement is denied, the BMS Policy Unit notifies the CSM electronically of the decision. The local office notifies the client in writing of the denial. 10.6.6.B Delaying the Medicaid Benefit Issuance The Medicaid benefit issuance is not delayed under any circumstances. 10.6.6.C Procedures for Medical ID Cards That Are Returned and Incorrect 10.6.6.C.1 Returned Medical ID Cards Upon receipt of these cards, the State Office mails them to the appropriate local office.