Current through Register Vol. 49, No. 9, September, 2024
(b)
Adjustments or
Recoveries
The State complies with the requirements of section 1917(b) of
the Act and regulations at
42 CFR 433.36(h) -
(i).
Adjustments or recoveries for Medicaid claims correctly paid
are as follows:
(1) For permanently
institutionalized individuals, adjustments or recoveries are made from the
individual's estate or upon sale of the property subject to a lien imposed
because of medical assistance paid on behalf of the individual for services
provided in a nursing facility, ICF/MR, or other medical institution.
X Adjustments or recoveries are made
for all other medical assistance paid on behalf of the
individual.
(2)
X The State determines "permanent institutional
status" of individuals under the age of 55 other than those with respect to
whom it imposes liens on real property under §1917(a)(1)(B) (even if it
does not impose those liens).
(3)
For any individual who received medical assistance at age 55 or older,
adjustments or recoveries of payments are made from the individual's estate for
nursing facility services, home and community-based services, and related
hospital and prescription drug services.
__ In addition to adjustment or
recovery of payments for services listed above, payments are adjusted or
recovered for other services under the State plan as listed below:
None
4.17(b) Adjustments or Recoveries
(3)
Limitations on Estate Recovery - Medicare Cost Sharing:
(i) Medical assistance for Medicare cost
sharing is protected from estate recovery for the following categories of dual
eligibles: QMB, SLMB, QI, QDWI, QMB+, SLMB+. This protection extends to medical
assistance for four Medicare cost sharing benefits: (Part A and B premiums,
deductibles, coinsurance, co-payments) with dates of service on or after
January 1, 2010. The date of service for deductibles, coinsurance, and
co-payments is the date the request for payment is received by the State
Medicaid Agency. The date of service for premiums is the date the State
Medicaid Agency paid the premium.
(ii) In addition to being a qualified dual
eligible the individual must also be age 55 or over. The above protection from
estate recovery for Medicare cost sharing benefits (premiums, deductibles,
coinsurance, co-payments) applies to approved mandatory (i.e., nursing
facility, home and community-based services, and related prescription drugs and
hospital services) as well as optional Medicaid services identified in the
State plan, which are applicable to the categories of duals referenced
above.
