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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
An “overpayment” occurs when Medicaid ( MA ) benefits are paid for someone who was not eligible for them, or when MA payments are made in an incorrect amount. The amount of recovery may not exceed the amount of the MA benefits incorrectly provided. Some examples of how overpayments occur are:
Concealing or not reporting income/
Failure to report a change in income or assets.
Providing misinformation, at the time of application, regarding any information that would affect eligibility.
Initiate recovery for a MA overpayment if the incorrect payment resulted
from one of the following:
Client Error
Client error exists when an applicant, recipient, or any
other person responsible for giving information on the client’s behalf,
unintentionally misstates facts, which results in the client receiving
a benefit that s/he is not entitled to or more benefits than s/he us entitled
to. Client error occurs when there is a:
Misstatement or omission of facts by a client,
or any other person responsible for giving information on the client’s
behalf, at a MA application or review.
Failure on the part of the client, or any
person responsible for giving information on the client’s behalf, to
report changes in income or assets.
A MA client is responsible for notifying his/her Economic
Support ( ES ) worker of changes within 10 days of the occurrence.
An overpayment occurs if the change would have adversely
affected eligibility benefits or the post eligibility contribution amount
(cost share, patient liability).
Fraud
Fraud is also known as Intentional Program Violation ( IPV
). Fraud occurs when a client intentionally omits or provides
erroneous information at the time of application or review. If there
is a suspicion that fraud has occurred, see 6.2.4
for information about referral to the District Attorney ( DA ).
Client Loss of an Appeal
Benefits a client receives due only to a fair hearing order
can be recovered if the client loses the appeal.
A client may choose to continue to receive benefits pending an appeal decision. If the appeal decision is that the client was ineligible, the benefits received while awaiting the decision can be recovered. If an appeal results in an increased patient liability, cost share, or premium, recover the difference between the initial amount and the new amount.
Do not initiate recovery for a MA overpayment if it resulted from a non-client error, including the following situations:
The client reported the change timely, but you could not close the case or reduce the benefit due to the 10-day notice requirement.
Agency error (keying error, math error, failure
to act on a reported change, etc).
Normal prospective budgeting projections based on best available information.
A change in the MA category if the benefits in the new category are the same as the original, and the post-eligibility contribution, if any, remains the same.
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Example: Mom and child are on AFDC-MA . They concealed income which would have made the mom ineligible. The child would still have been eligible under Healthy Start. Only recover the incorrect payments made for the mom. |
This page last updated in Release Number : 03-01
Release Date: 01/01/03
Effective Date: 01/01/03
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