Personal tools

Issue Alert - Reimbursement of Medical Expenses

Document Actions
Date:

Jul 10, 2006

Program Area:

Medicaid

Issue Summary:

The procedure for reimbursement of medical expenses has been revised. A client may be eligible for reimbursement of medical expenses he or she paid to providers for a retroactive eligibility period.

Persons Affected:

Medicaid applicants who pay out-of-pocket, Medicaid-covered, medical expenses while waiting for Medicaid approval.

For More Information:

Center for Civil Justice 320 S. Washington, 2nd Floor Saginaw, MI 48607 (989) 755-3120, (800)724-7441 Fax: (989) 755-3558 E-mail: info@ccj-mi.org

Michigan Poverty Law Program 611 Church Street, Suite 4A Ann Arbor, MI 48104-3000 (734) 998-6100 (734) 998-9125 Fax


Background

The Schott v. Olszewski, 401 F.3d 682 (6th Cir. 2005)decision states that Medicaid recipients who had their applications rejected when they first applied for Medicaid coverage and then were successful in having that adverse ruling overturned on appeal are entitled to reimbursement of their out-of-pocket expenses. Policy has been implemented to follow the court's decision.

What's Happening?

When a hearing request based on a Medicaid denial is received, The Department of Human Services (DHS) is to send or give the client an DHS-333, Retroactive Period/Corrective Action Eligibility Notice. This notice explains the potential for reimbursement of
paid medical expenses after a DHS denial that is overturned on appeal by DHS, an ALJ, or a court. To be eligible for reimbursement, the payment must be for a Medicaid covered care or service that is provided on or after February 2, 2004. The client is to be given or sent the fomr whe he or she s notified of the overturned Medicaid eligibility decision.
A client may be eligible for reimbursement of medical expenses paid to providers for a retroactive eligibility period Medicaid covered care or service. A medical payment for care or services received in a client’s
retroactive period may be reimbursable if it is made between a DHS denial and 10 days after the date an eligibility determination is issued as a result of the hearing request. A client may also be eligible for reimbursement of medical expenses paid to providers for care or services received after the DHS application. The corrective action period covers medical expenses paid to providers between the date a DHS administrative hearing request is filed and 10 days after the
date an eligibility determination is issued as a result of the hearing request. The client must show that the original denial was incorrect for corrective action reimbursements.
Example #1: A client submits his income and expense information but forgets to include proof of health insurance premiums or child support payments and is denied due to excess income. If the client appeals the DHS denial and provides the missing information, this could allow the initial denial, correct when issued, to be overturned. If the care or service for which the client made the medical payment was received after the client’s application that resulted in the DHS denial, the payment would not be eligible for reimbursement.
Example #2:
• 2/20/06 application for Medicaid and retroactive Medicaid is received by DHS.
• 4/5/06 the application is denied.
• 5/3/06 a hearing request is received in the local DHS office.
• 6/7/06 the ALJ overturns the denial and determines the client is eligible
for Medicaid.
• 6/14/06 the specialist processes the Medicaid opening.
If the medical payment was for care or services received in the retroactive period, the client is eligible for reimbursement for payments between 4/5/06, (the original denial date) and 6/24/06, (10 days after the second eligibility notice is mailed). If the medical payment was for care or services after the retroactive period, the corrective action period covers payments made between 5/3/06, (the date the hearing request was received by DHS) and 6/24/06, (10 days after the second eligibility notice was mailed)

Finding Help

Most legal aid and legal services offices handle these types of cases, and they do not charge a fee.

You can locate various sources of legal and related services, including the free legal aid office that serves your county, at MichiganLegalAid.org.

You can also look in the yellow pages under "attorneys" or call the toll-free lawyer referral number, (800) 968-0738.