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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
6.2.1.1 Recoverable Overpayments
6.2.1.2 Non-Recoverable Overpayments
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 Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. or assets.
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 (financial or non-financial) facts, which results in the client receiving a benefit that s/he is not entitled to or more benefits than s/he is entitled Failure to report non-financial facts that impact eligibility or cost share amounts is a recoverable overpayment effective July 27, 2005. For ongoing cases, September 1, 2005 is the earliest a claim can be established for failure to report a non-financial change. For applications on/after July 27, 2005, overpayment claims can be established effective with the application date.
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.
or
Failure on the part of the client, or any person responsible for giving information on the client’s behalf, to report changes in financial (income, assets, expenses, etc.) or non-financial information that affects eligibility, premium, patient liability or cost share amount.
A MA client is responsible for notifying his/her IM 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).
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Example 1: Joe and his family were determined eligible for BadgerCare with a premium in July. In November, Joe’s worker learned that, effect August 1st, Joe had access to health insurance for his family through his employer, with the employer paying more than 80% of the premium for this coverage. The worker entered the information in CARES and closed the case effective November 30th. |
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Example 2: Sally, determined eligible for waivers in January with a cost share, experienced a reduction in her health insurance expense in July, but did not report that to her worker until her November review. The worker made the changes in CARES and increased her cost share for December. |
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Example 3: Shana was determined eligible for Well Woman Medicaid (WWWMA) in February. She had private insurance, but due to a waiting period for preexisting conditions, her treatments weren’t covered. The waiting period ended July 31st, and the private insurance began to cover Shana’s treatment effective August 1st. Shana did not report this to her worker so MA continued to pay some service costs for Shana until the worker closed the case effective November 30. Since her case would have closed August 31st if she had reported the change timely, Shana has an overpayment for September through November. What can now be recovered – Giving AA notice, WWWMA would have closed August 31, 2005. The Fee For Service claims paid for September, October and November are recoverable. |
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Example 4: John and his family were determined eligible for BadgerCare in June. John accepted a new job in South Carolina and the family moved out of state on July 20th. Since they were no longer residents of Wisconsin, they were no longer eligible for BC. However, because the move to South Carolina was not reported, capitation payments continued to be made for John and his family until the worker closed the case effective December 31st.
What can now be recovered? |
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Example 5: Susan was determined eligible for Healthy Start in January; she was pregnant with a due date of August 15th. On February 3rd, she miscarried but did not report this change to her worker. Her HS eligibility continued until the worker closed the case effective October 31st. Once she was no longer pregnant, she would have been eligible for the two month extension only. Susan was not eligible for the months May through October. |
Fraud
Fraud is also known as Intentional Program Violation ( IPV).
Fraud exists when an applicant, recipient, or any other person responsible for giving information on the client's behalf does any of the following:
Intentionally makes or causes to be made a false statement or representation of fact in an application for a benefit or payment.
Intentionally makes or causes to be made a false statement or representation of a fact for use in determining rights to benefits or payments.
Having knowledge of an event affecting initial or continued right to a benefit or payment and intentionally failing to disclose such event.
Having made application to receive a benefit or payment and intentionally uses any or all of the benefit or payment for something other than the intended use and benefit of such persons listed on the application.
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 AFDC-MA is the category of Medicaid that is based on rules for the Aid to Families with Dependant Children Program (AFDC) that were in effect on July 16, 1996.. 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 : 06-02
Release Date: 07/14/06
Effective Date: 07/27/05
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