6.2.2 Overpayment Calculation

6.2.2.1 Overpayment Period

6.2.2.2 Overpayment Amount

6.2.2.2.1 Increased Liability Cost Share

6.2.2.2.2 Deductible

6.2.2.2.3 Premiums

6.2.2.2.3.1 Overpayments for Individuals Eligible for FPW Benefits

6.2.2.2.4 Determining Liable Individual

6.2.2.1 Overpayment Period

If the overpayment is a result of a misstatement or omission of fact during an initial MA application, determine the period for which the benefits were determined incorrectly and determine the appropriate overpayment amount (6.2.2.2).

The ineligible period should begin with the application month.

For ineligible cases, if the overpayment is a result of failure to report a change, calculate the date the change should have been reported and which month the case would have closed or been adversely affected if the change had been reported timely.

For ineligible cases, if the overpayment was the result of fraud, determine the date the fraudulent act occurred.  The period of ineligibility should begin the date the case would have closed or been adversely affected allowing for proper notice.  If an overpayment exists, but the case is still being investigated for fraud, establish the claim so collection can begin promptly.  Prosecution should not delay recovery of a claim.

6.2.2.2 Overpayment Amount

Use the simulation function in CARES Client Assistance for Re-employment & Economic Support to determine a client’s eligibility, nursing home liability, premium or cost share (if applicable) based on the corrected information ( CARES Guide Chapter VIII, 1.4.1).  Use the actual income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. received by the client in determining if an overpayment has occurred.

To calculate the overpayment amount, use the RC ( recipient claims ) screen on MMIS.  The overpayment amount depends on the MA category and whether the case is fee-for-service or enrolled in a HMO.

If a case was ineligible due to excess income recover :
 

1. The lesser of FFS services MA paid or the amount the client would have paid toward a deductible (If eligible for a deductible)

or

2. The lesser of what the client paid would have paid toward the deductible and the amount MA has spent on HMO capitation payments.
    

If a case/individual was ineligible for reasons other than excess income or not eligible for a deductible) recover the:

1. Amount paid for the medical services provided if the case is fee-for-service.  
   
   or
    

2. Managed care organization’s capitation rate, less any contribution made by the client (ex. premium, cost share) if the case members are enrolled in a MA managed care organization.  The capitation rate is the monthly amount MA pays to the client’s managed care organization.
    

For the overpayment amounts for institutional (6.2.2.2.1), waiver (6.2.2.2.1), BadgerCare (6.2.2.2.3), Medicaid Purchase Plan (6.2.2.2.3),  deductible (6.2.2.2.2) and Family Planning Waiver ( FPW ) 6.2.2.2.3.1 cases see the appropriate sections.

6.2.2.2.1 Institutional Overpayments

The overpayment amount for an institutional case is the amount MA paid.  

Note:  Patient liability should not be subtracted from the claims paid by MA when determining the overpayment amount.

 

6.2.2.2.1.1  Overpayment as a result of Misstatement or omision of fact
 

If a misstatement or omission of fact results in an increased nursing home liability or waivers cost share, the difference between the correct liability/cost share amount and the one the client originally paid is the overpayment amount.

Do not send a HCF 10110 (formerly DES 3070) to retroactively increase the patient liability on MMIS.

Family Care

For Family Care ( FC ) cases in which an omission of fact results in an increased Family Care liability or cost share, complete the following:

1. Recalculate the cost share or FC liability for any months that would have been affected.
    

2. Calculate the difference between the paid cost share or FC liability amount and the new cost share or FC liability amount.
    

3. Send the client a notice indicating the correct cost share for the months in question.  Indicate on the notice the cost share amount still owed to the Care Management Organization ( CMO ) for each month in question.  Do not attempt to recover the overpayment.
    

4. Report the new cost share amount to the CMO.
    

It is the CMO’s responsibility to collect the difference between the cost share already paid and the correctly calculated cost share amount.  This amount is not an overpayment of MA funds, but is the amount that the client owes the CMO directly.

6.2.2.2.2 Deductible

If a client error increases the deductible before the deductible is met, there is no overpayment.  Recalculate eligibility and notify the client of the new deductible amount.

If the client met the incorrect deductible and MA paid for services after the deductible had been met, there is an overpayment.  Recover the difference between the correct deductible amount and the previous deductible amount or the amount of claims over the six month period (whichever is less) .

If the client was ineligible for the deductible, determine the overpayment amount.  If the client prepaid his/her deductible, deduct any amount s/he paid toward the deductible from the overpayment amount.

6.2.2.2.3 Premiums

If a BadgerCare ( BC ) or Medicaid Purchase Plan ( MAPP The Medicaid Purchase Plan (MAPP) offers people with disabilities who are working or interested in working the opportunity to obtain health care coverage through the Wisconsin Medicaid Program. ) case was still open for the timeframe in question, but there was an increase in the premium, recover the difference between the premium paid and the amount owed for each month in question.  To determine the difference, determine the premium owed and view the premium amount paid on CARES screen AGPT.  

BadgerCare

If the case was ineligible for BC, recover the amount of medical claims paid by the state and/or the capitation rate.  Deduct any amount paid in premiums (for each month in which an overpayment occurred) from the overpayment amount (6.2.2.2).
 

The overpayment amount is the difference between the premium paid and premium owed even if the premium that was paid was $0.

MAPP

If the case was ineligible for MAPP, recover the amount of medical claims paid by the state.  Deduct any amount s/he paid in premiums (for each month in which an overpayment occurred) from the overpayment amount.

6.2.2.2.3.1 Overpayments for Individuals Eligible for FPW Benefits

If an individual or case was ineligible for MA or BC  but would have been eligible for FPW benefits, the calculation of the ultimate Medicaid overpayment amount is as follows:

1. If the incorrect/overpaid Medicaid benefits were “fee for service” medical claims paid by the state, recover the amount of benefits that were actually paid by the state minus any premiums which the client may have paid and the amount of any actual FPW services that were provided.
    

2. If the incorrect /overpaid Medicaid benefits were paid by an HMO, recover the HMO capitation rate paid by the state minus any premiums which the client may have paid and the “average” (currently $28.60) monthly cost of Medicaid FPW services.
    

6.2.2.2.3.2 Overpayments for QMB cases

The overpayment amount for QMB cases is:

1. Medicare Part A premium if paid by the state (some are free others are paid by the state).
   
   plus
    

2. Medicare Part B premium
   
   plus
    

3. Medicare deductibles
   
   plus
    

4. Medicare Co-insurance
    

Use the MMIS RC screen to determine if any Medicare deductibles and co-insurance payments were made by the state.

6.2.2.2.4 Determining Liable Individual

Except for minors, collect overpayments from the MA client, even if the client has authorized a representative to complete the application or review for him/her.

If a minor received MA in error, make the claim against the minor’s parent(s) or legally responsible relative if the parent or legally responsible relative was living with the minor at the time of the overpayment.

This page last updated in Release Number: 08-01

Release Date: 01/07/08

Effective Date: 01/01/08