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Medicaid Reimbursement of Home Care and other Medical Expenses

Views: 34670
Posted: 19 Feb, 2009
by David Silva (New York Legal Assistance Group)
Updated: 10 Sep, 2014
by Emily Unger (New York Legal Assistance Group)

Reimbursement in General

Because Medicaid coverage can be retroactive up to three months, it is possible for a Medicaid applicant -- or his or her family member who paid the applicant's medical expenses -- to get reimbursed for some of the home care costs and other medical bills they incurred and paid during the three calendar months before the month in which  they applied for Medicaid.  It is also possible to get reimbursed for home care  costs incurred between the date of application and the date Medicaid home care services start.  This article includes resources on getting Medicaid to reimburse for these costs.

November 2010 State Directive

On Nov. 22, 2010, the State Dept. of Health issued a new directive, 10ADM-09 - Reimbursement of Paid Medical Expenses Under 18 NYCRR §360-7.5(a), that clarifies the policy on reimbursement for both Medicaid and Family Health Plus (for which there is limited reimbursement available for delayed applications).  Significantly, the directive distinguishes between bills incurred BEFORE the Medicaid application, during the 3 calendar months before the date of the application ("retroactive period") and the "post-application" period, which is the period from the date of the application until the Medicaid card is issued.    While reimbursement is available for both of these two periods, Medicaid limits reimbursement during the "post-application" period to services provided by MEDICAID PROVIDERS -- when the applicant applies for Medicaid, s/he is supposed to be given information explaining that she must only use Medicaid providers from then on, or won't be reimbursed.   Medicaid will reimburse non-Medicaid providers for services provided during the 3 months before the month of the application. 

An EXCEPTION to the rule that only services by MEDICAID PROVIDERS will be reimbursed, for services provided after the application is filed, is made for bills incurred because of "error or delay" by the local district in approving the Medicaid application.   The ADM states, at page 7, "...[R]eimbursement in cases of district error or delay must not be limited to services provided by Medicaid enrolled providers. However, the provider must be lawfully qualified to provide the services and not be excluded or otherwise sanctioned by the Medicaid program."   For these bills, the rate of reimbursement is not limited to the Medicaid rate, but must be reasonable.  

The Attachments to the ADM include a chart explaining the different rules for the retroactive and post-application periods, and the required notices.

  • 10ADM-09 - Reimbursement of Paid Medical Expenses Under 18 NYCRR §360-7.5(a) (PDF, 51KB, 10pg.)

    • Attachment 1 (PDF, 19KB, 1pg.)(Chart explaining different rules for reimbursement for retroactive and post-application period, and also rules on reimbursement for Family Health Plus)

    • Attachment 2 (PDF, 12KB, 1pg.)(Form letter to Medicaid provider inviting submission of claim for services provided to an applicant for Family Health Plus, whose application was delayed)

    • Attachment 3 (PDF, 22KB, 1pg.)(OHIO-0031)(Claim Transmittal Form)(Local district uses this form if opts to transmit claim to State for State,  rather than local district , to make reimbursement to client)

    • Attachment 4 (PDF, 20KB, 1pg.)(OHIO-0032)(Medical Assistance Reimbursement Detail Form)(Local district must attach form to Notice denying reimbursement in amount requested)

    • Attachment 5 (PDF, 37KB, 2pg.)(NOTICE OF DECISION ON REIMBURSEMENT OF MEDICAL BILLS BY THE MEDICAL ASSISTANCE PROGRAM)

    • Attachment 5 MA Only-Spanish (PDF, 99KB, 2pg.)(Notice of Decision in Spanish)

Advocacy Tip:  Be Sure to Request Retroactive Effective Date of Coverage if you will be Seeking Retroactive Reimbursement

Medicaid eligibility is made by calendar month.   An applicant must be eligible on the 1st day of a month in order to be eligible that month.  This means bank accounts and other resources must have been below the applicable resource limits (see box 3 of this chart) on the 1st of the month to be eligible that month (new income received that month would not count because it is not a "resource" until the following month).

To be reimbursed for medical expenses paid during any month(s) in the retroactive period,  the applicant must have been found eligible for Medicaid during those months.   For example, Mrs. A applied in May.   She cannot be reimbursed for expenses she paid in April if she transferred $20,000 in assets in April, since she was not eligible in April.  

  • TIP -- On page 5 (Section G) of  the Medicaid application  make sure to check YES on Question 1 which asks,  "Does anyone applying have paid or unpaid medical or prescription bills for this month or the three months before this month? "   This question should prompt the Medicaid worker to request proof of financial eligibility (bankbooks, etc.) going back 3 months.  However, they often do not ask, and you should make sure to submit this proof and request a specific effective date back to one of the 3 months in the retroactive period.  Otherwise, they will just make the eligibility effective the month of application -- and reimbursement could be denied.

Reimbursement for Home Care Expenses

Medicaid, the health insurance program for people with limited income and assets, is one of the only insurance programs that covers long-term home health care services.  As a result, it is very common for people whose assets are over the Medicaid limit to spend their savings on home care services, and then apply for Medicaid home care once they are under the limit.

This memo describes the steps for getting home care reimbursement in New York City (some of the information applies State-wide).  The memo includes citation to the relevant case law.   Note that the November 2010 State directive posted above states that Medicaid will only reimburse Medicaid providers for the period after the Medicaid is filed.  This creates a problem in places like New York City, where the providers of Medicaid personal care/home attendant services cannot be hired for private-paid services.   Many of these agencies also operate a "Licensed Home Care Services Agency" (LHCSA) which may be privately paid, but.. they are not Medicaid providers!   The only home care agencies that are both Medicaid providers and that one may privately pay are Certified Home Health Agencies, which have higher costs because they include extensive nursing supervision.

Here is a list of documents that must be completed and submitted with your NYC reimbursement request:

Reimbursement for Expenses other than Home Care Expenses

A Medicaid applicant (or his or her family or other person who paid their expenses) can also get reimbursed for other types of medical expenses incurred and paid for during the retroactive period -- the three calendar months before the month of the application.   To request reimbursement for these expenses, send a request with copies of the bills, proof of payment (canceled checks, credit card charges, and/or receipts), and the Medicaid notice showing that Medicaid was approved and the effective date.  

In NYC, reimbursement requests other than home care should be addressed to:

Office of Financial and Program Planning
Medicaid Client Reimbursement Unit
785 Atlantic Ave.
Brooklyn NY 11238

929-221-0845 (phone non-home care reimbursement )
929-221-1193 (phone home care reimbursement )
718-636-7750 (fax home care)

HRA published on 2/6/09 a fact sheet for getting reimbursement of paid medical or dental bills -- but note that the address given at the end of this HRA fact sheet  for sending reimbursement requests for home care services other than LPN services has changed.  It is now  the Medicaid Home Care Services Program, Reimbursement Unit, 330 W. 34th St.., 9th floor, New York, NY 10001. 

If you are dealing with New York Medicaid in a county outside of NYC, you should contact your local District of Social Services to find out how to request reimbursement.  The laws and regulations cited in the memo apply statewide.


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
file HRA Reimbursement FACT SHEET 2 6 09.pdf (47 kb)
file Medicaid Homecare Reimbursement.pdf (319 kb)
file Reimbursement Form.pdf (11 kb)
file Reimbursement Worksheet.xlt (21 kb)
file Homecare Reimbursement Affidavit NEW.dot (30 kb)
file Substitute_W9_2013Form.pdf (32 kb)
file MAPDR-01 2014 NYS Income and Resource Standards and FPL 6-24-2014.pdf (153 kb)

Also read
document Medicaid Personal Care or Home Attendant Services
document Medicaid Certified Home Health Agency (CHHA) Services
document "Ensure" and Enteral Nutritional Supplements - When does Medicaid Pay for it? 2013 Changes for Adults

External links
http://home2.nyc.gov/html/selltonyc/pdf/fms_substitute_form_w9.pdf
http://www.health.state.ny.us/health_care/medicaid/ldss.htm
http://www.nyc.gov/html/hra/downloads/pdf/income_level.pdf

Also listed in
folder Medicaid -> Financial Eligibility
folder Medicaid -> Other Services

Prev   Next
Medicaid Certified Home Health Agency (CHHA) Services     Applying for Medicaid Personal Care Services Outside NYC


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