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West Virginia Income Maintenance Manual Chapter 26

West Virginia Income Maintenance Manual Page 11 Chapter 26 Medicaid Work Incentive (M-WIN)

If the Department delayed requesting necessary verification or acting on the information already received, benefits are retroactive to the date eligibility would have been established had the DOHS acted in a timely manner. If an application has not been acted on within a reasonable period of time, unless the delay is due to factors beyond the control of the DOHS, the client is eligible to receive direct reimbursement for out-of-pocket medical expenses. See Section 10.6.6. Agency Delay Example: Poppy Elm applies for M-WIN on December 5 and explains she is scheduled for surgery on January 2. The Worker explains the importance of paying the enrollment fee in December to provide Medicaid coverage for January. Poppy pays her enrollment fee December 28. The Worker returns January 5 and approves M-WIN effective February without backdating M- WIN eligibility to include January. The Worker corrects the case; however, Ms. Elm filled prescriptions January 1 totaling $121. The pharmacy refuses to bill Medicaid. The delay was within the control of the DOHS; therefore, Ms. Elm is eligible for direct reimbursement for out-of-pocket medical expenses. 26.3.7 PAYEE The client is the payee. 26.3.8 BEGINNING DATE OF ELIGIBILITY The beginning date of eligibility is the first day of the month following the date the enrollment fee is received. 26.3.9 CLIENT NOTIFICATION • The first letter notifies the client whether or not he meets all requirements, except payment of the enrollment fee. This notice contains an enrollment fee payment stub that is returned with the client’s payment. See Section 26.2.5. • If the client meets all requirements, the second letter is an approval if the enrollment fee is received or a denial if the enrollment fee is not received.