Iowa Admin. Code r. 441-75.28 - Recovery
(1)
Definitions.
"Administrative overpayment" means medical
assistance incorrectly paid to or for the
"Agency error" means medical assistance
incorrectly paid to or for the
1.Misfiring or loss of forms or
documents.
2. Errors in typing or
copying.
3. Computer input
errors.
4. Mathematical
errors.
5. Failure to determine
eligibility correctly or to certify assistance in the correct amount when all
essential information was available to the department .
6. Failure to make prompt revisions in
medical payment following changes in policies requiring the changes as of a
specific date.
"
"
"
"Premiums paid for medical assistance" means
monthly premiums assessed to a
(2)
Amount subject to
recovery. The department shall recover from a client all Medicaid
funds incorrectly expended to or on behalf of the client and all unpaid
premiums assessed by the department for medical assistance. The incorrect
expenditures or unpaid premiums may result from client or agency error or
administrative overpayment.
(3)
Notification. All clients shall be promptly notified on Form
470-2891, Notice of Medical Assistance Overpayment, when it is determined that
assistance was incorrectly expended or when assessed premiums are unpaid.
a. Notification of incorrect expenditures
shall include:
(1) For whom assistance was
paid;
(2) The period during which
assistance was incorrectly paid;
(3) The amount of assistance subject to
recovery; and
(4) The reason for
the incorrect expenditure.
b. Notification of unpaid premiums shall
include:
(1) The amount of the premium;
and
(2) The month covered by the
medical assistance premium.
(4)
Source of recovery.
Recovery shall be made from the client or from parents of children under the
age of 21 when the parents completed the application and had responsibility for
reporting changes. Recovery may come from income, resources, the estate, income
tax refunds, and lottery winnings of the client .
(5)
Repayment.The repayment
of incorrectly expended Medicaid funds shall be made to the department .
However, repayment of funds incorrectly paid to a nursing facility, a
Medicare-certified skilled nursing facility, a psychiatric medical institution
for children, an intermediate care facility for persons with an intellectual
disability, or mental health institute enrolled as an inpatient psychiatric
facility may be made by the client to the facility. The department shall then
recover the funds from the facility through a vendor adjustment.
(6)
Appeals.The client shall
have the right to appeal the amount of funds subject to recovery under the
provisions of 441-Chapter 7.
(7)
Estate recovery. Medical assistance, including the amount the
state paid to a managed care organization (MCO) for provision of medical
services, also called capitation fees, is subject to recovery from the estate
of a Medicaid member , the estate of the member 's surviving spouse, or the
estate of the member 's surviving child as provided in this subrule. Effective
January 1, 2010, medical assistance that has been paid for Medicare cost
sharing or for benefits described in Section 1902(a)(10)(E) of the Social
Security Act is not subject to recovery. All assets included in the estate of
the member , the surviving spouse, or the surviving child are subject to probate
for the purposes of medical assistance estate recovery pursuant to Iowa Code
section 249A.53(2)
"d." The classification of the debt is
defined at Iowa Code section
633.425(7).
a.
Definitions.
"Capitated payment/rate" means a monthly
payment to the contractor on behalf of each
"Estate." For the purpose of this subrule,
the "estate" of a Medicaid
"Managed care organization" means an entity
that (1) is under contract with the
b.
Debt due for member 55
years of age or older. Receipt of medical assistance when a member is
55 years of age or older creates a debt due to the department from the member 's
estate upon the member 's death for all medical assistance provided on the
member 's behalf on or after July 1, 1994.
c.
Debt due for member under the age
of 55 in a medical institution .
(1)
Receipt of medical assistance creates a debt due to the department from the
member 's estate upon the member 's death for all medical assistance provided on
the member 's behalf on or after July 1, 1994, when the member :
1. Is under the age of 55; and
2. Is a resident of a nursing facility, an
intermediate care facility for persons with an intellectual disability, or a
mental health institute; and
3.
Cannot reasonably be expected to be discharged and return home.
(2) If the member is discharged
from the facility and returns home before staying six consecutive months, no
debt will be assessed for medical assistance payments made on the member 's
behalf for the time in the institution.
(3) If the member remains in the facility for
six consecutive months or longer or dies before staying six consecutive months,
the department shall presume that the member cannot or could not reasonably be
expected to be discharged and return home and a debt due shall be established.
The department shall notify the member of the presumption and the establishment
of a debt due.
d.
Request for a determination of ability to return home. Upon
receipt of a notice of the establishment of a debt due based on the presumption
that the member cannot return home, the member or someone acting on the
member 's behalf may request that the department determine whether the member
can or could reasonably have been expected to return home.
(1) When a written request is made within 30
days of the notice that a debt due will be established, no debt due shall be
established until the department has made a decision on the member 's ability to
return home. If the determination is that there is or was no ability to return
home, a debt due shall be established for all medical assistance as of the date
of entry into the institution.
(2)
When a written request is made more than 30 days after the notice that a debt
due will be established, a debt due will be established for medical assistance
provided before the request even if the determination is that the member can or
could have returned home.
e.
Determination of ability to return
home. When the member or someone acting on the member 's behalf
requests that the department determine if the member can or could have returned
home, the determination shall be made by the Iowa Medicaid enterprise (IME)
medical services unit.
(1) The IME medical
services unit cannot make a determination until the member has been in an
institution at least six months or after the death of the member , whichever is
earlier. The IME medical services unit will notify the member or the member 's
representative and the department of the determination.
(2) If the determination is that the member
can or could return home, the IME medical services unit shall establish the
date the return is expected or could have been expected to occur.
(3) If the determination is that the member
cannot or could not return home, a debt due will be established unless the
member or the member 's representative asks for a reconsideration of the
decision. The IME medical services unit will notify the member or the member 's
representative and the department of the reconsideration decision.
(4) If the reconsideration decision is that
the member cannot or could not return home, a debt due will be established
against the member unless the decision is appealed pursuant to 441-Chapter 7.
The appeal decision will determine the final outcome for the establishment of a
debt due and the period when the debt is established.
f.
Debt collection.
(1) A nursing facility participating in the
medical assistance program shall notify the IME revenue collection unit upon
the death of a member residing in the facility by submitting Form 470-4331,
Estate Recovery Program Nursing Home Referral.
(2) Upon receipt of Form 470-4331 or a report
of a member 's death through other means, the IME revenue collection unit will
use Form 470-4339, Medical Assistance Debt Response, to request a statement of
the member 's assets from the member 's personal representative. The
representative shall sign and return Form 470-4339 indicating whether assets
remain and, if so, what the assets are and what higher priority expenses exist.
EXCEPTION: The procedures in this subparagraph are not necessary when a probate
estate has been opened, because probate procedures provide for an inventory, an
accounting, and a final report of the estate.
g.
Waiving the collection of the
debt.
(1) The department shall waive
the collection of the debt created under this subrule from the estate of the
member to the extent that collection of the debt would result in either of the
following:
1. Reduction in the amount received
from the member 's estate by a surviving spouse or by a surviving child who is
under the age of 21, blind , or permanently and totally disabled at the time of
the member 's death.
2. Creation of
an undue hardship for the person seeking a waiver of estate recovery. Undue
hardship exists when total household income is less than 200 percent of the
poverty level for a household of the same size, total household resources do
not exceed $10,000, and application of estate recovery would result in
deprivation of food, clothing, shelter, or medical care such that life or
health would be endangered. For this purpose, "income" and "resources" shall be
defined as being under the family investment program.
(2) To apply for a waiver of estate recovery
due to undue hardship, the person shall provide a written statement and
supporting verification to the department within 30 days of the notice of
estate recovery pursuant to Iowa Code section 249A.53(2).
(3) The department shall determine whether
undue hardship exists on a case-by-case basis. Appeals of adverse decisions
regarding an undue hardship determination may be filed in accordance with
441-Chapter 7.
h.
Amount waived. If collection of all or part of a debt is
waived pursuant to paragraph 75.28(7)"g," to the extent that
the person received the member 's estate, the amount waived shall be a debt due
from the following:
(1) The estate of the
member 's surviving spouse, upon the death of the spouse.
(2) The estate of the member 's surviving
child who is blind or has a disability, upon the death of the child.
(3) A surviving child who was under 21 years
of age at the time of the member 's death, when the child reaches the age of
21.
(4) The estate of a surviving
child who was under 21 years of age at the time of the member 's death, if the
child dies before reaching the age of 21.
(5) The hardship waiver recipient , when the
hardship no longer exists.
(6) The
estate of the recipient of the undue hardship waiver, at the time of death of
the hardship waiver recipient .
i.
Impact of asset disregard on debt
due. The estate of a member who is eligible for medical assistance
under subrule 75.5(5) shall not be subject to a claim for medical assistance
paid on the member 's behalf up to the amount of the assets disregarded by asset
disregard. Medical assistance paid on behalf of the member before these
conditions shall be recovered from the estate, regardless of the member 's
having purchased precertified or approved insurance.
j.
Interest on debt.
Interest shall accrue on a debt due under this subrule at the rate provided
pursuant to Iowa Code section
535.3,
beginning six months after the death of a Medicaid member , the surviving
spouse, or the surviving child, or upon the child's reaching the age of
21.
k.
Reimbursement to
county. If a county reimburses the department for medical assistance
provided under this subrule and the amount of medical assistance is
subsequently repaid through a medical assistance income trust or a medical
assistance special needs trust as defined in Iowa Code chapter 633C, the
department shall reimburse the county on a proportionate
basis.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.