Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 469 - ASSISTANCE TO THE AGED, BLIND, OR DISABLED PROGRAM
Chapter 2 - ELIGIBILITY REQUIREMENTS
Section 469-2-011 - COOPERATION IN OBTAINING THIRD PARTY MEDICAL PAYMENTS

Universal Citation: 469 NE Admin Rules and Regs ch 2 ยง 011

Current through September 17, 2024

The application for State Disability Program medical assistance constitutes an automatic assignment of the recipient's rights to third party payments made on behalf of the recipient for medical care or services which are payable under the State Disability Program. As a requirement for assistance, the recipient must also cooperate, unless good cause for noncooperation can be verified, in securing any third party medical payments.

011.01 THIRD PARTY PAYMENTS NOT ASSIGNED. The following third party payments are not subject to the automatic assignment provision:

(A) Medicare benefits; and

(B) Payments from income-producing policies which subsidize the individual's income while the individual is hospitalized or receiving medical care, regardless of the type of medical service being provided.

011.02 COOPERATION REQUIREMENTS. The recipient must cooperate in obtaining third party payments unless good cause for noncooperation can be established. Cooperation includes any or all of the following:

(1) Providing complete information about third party medical coverage for the recipient or the children in their care. This includes third party medical coverage provided by any other person or agency;

(2) Providing any additional information or signing claim forms which may be necessary for identification and collection of potential third party payments;

(3) Appearing as a witness in a court or another proceeding, if necessary;

(4) Notifying the Department of any actions being initiated to recover money from a liable third party for medical care or services. This includes the identity of the third party and the entire amount of any settlement, court award, or judgment; and

(5) Reimbursing the Department, or paying the provider, from any payments received directly from a third party for any services payable by State Disability Program Medical Assistance; and

(6) Taking any other reasonable steps to secure medical support payments.

011.02(A) REFUSAL TO COOPERATE. Non-cooperation by the recipient is based on the individual's failure or refusal to fulfill the requirements listed in this Section.

011.02(B) OPPORTUNITY TO CLAIM GOOD CAUSE.

011.02(C) NOTIFICATION OF RIGHTS. The individual must be notified of the right to claim good cause for non-cooperation at the intake interview, redetermination, or whenever cooperation becomes an issue.
011.01(C)(i) DEPARTMENT'S ACTIONS IF GOOD CAUSE CLAIMED. If the recipient claims good cause, the Department will:
(1) Explain that the individual has the burden of establishing the existence of a good cause circumstance; and

(2) Obtain a signed statement from the recipient listing the reason for claiming good cause. The individual is allowed 20 days to present evidence of the claim.

011.01(C)(ii) ACCEPTABLE CIRCUMSTANCES FOR GOOD CAUSE. Good cause claims must be substantiated by signed statements. When documentary evidence is not available, the individual must furnish sufficient information as to the location of the information.
011.01(C)(ii)(1) DOCUMENTARY EVIDENCE. Documentary evidence which indicates these circumstances includes:
(a) Medical records which document physical or emotional health history and present physical or mental health of the recipient;

(b) Written statements from a physician or mental health professional indicating the diagnosis or prognosis concerning the individual's physical or emotional condition;

(c) Court, medical, criminal, protective services, social services, psychological, or law enforcement records which indicate that the third party might inflict serious physical or emotional harm on the individual; or

(d) Signed statements from individuals other than the recipient with knowledge of the circumstances which provide the basis for the claim.

011.01(C)(ii)(2) EVIDENCE NOT SUBMITTED BY RECIPIENT. When corroborative evidence is not submitted in support of a claim:
(a) The Department investigates the good cause claim when it is believed that the claim is credible without corroborative evidence and the evidence is not available; and

(b) The Department will find good cause if the recipient's statement and the investigation indicate that the individual has good cause for refusing to cooperate.

011.01(C)(ii)(3) DEPARTMENT. CONSIDERATIONS. If the determination of good cause is not substantiated by documentary evidence, the following evidence must be considered:
(a) The present physical or mental state of the recipient;

(b) The physical or mental health history of the recipient;

(c) Intensity and probable duration of the physical or mental upset; and

(d) The degree of cooperation required by the recipient.

011.01(C)(ii)(4) DECISION ON GOOD CAUSE. The recipient will receive written notice of the Department's decision on good cause. If it is determined that good cause does not exist, the individual is allowed ten days from the date that the notice of action was mailed to respond. If the recipient does not cooperate, withdraw the application or request the case closed, and a sanction is imposed.

011.01(C)(ii)(5) DELAY OF ASSISTANCE PENDING DETERMINATION. The good cause determination does not deny, delay, or discontinue assistance, while it is pending, if the recipient has complied with the requirements of providing acceptable evidence or other necessary information. In most instances, a good cause determination must be made within 30 days following the receipt of a good cause claim.

011.01(C)(ii)(6) REVIEW OF GOOD CAUSE. At the time of each redetermination, review a good cause claim based on a circumstance that is subject to change. If circumstances remain the same, no action is required. A new determination is necessary if circumstances have changed. If good cause no longer exists, the requirement to cooperate is enforced.

011.02(D) SANCTION FOR REFUSAL TO COOPERATE. If the recipient fails or refuses to cooperate and there is no good cause claim or determination, the appropriate sanction is applied. If the reason for non-cooperation is the recipient's failure or refusal to provide information about or obtain third party medical payments, the individual is ineligible for grant and medical. Ineligibility continues until the individual cooperates or cooperation is no longer an issue.

011.02(E) THIRD PARTY MEDICAL PAYMENTS RECEIVED DIRECTLY. If the recipient receives a third party medical payment directly, and the medical expense for which the third party medical payment is intended is payable by the State Disability Program Medical Assistance, the payment is considered unearned income unless reimbursed by the recipient. If the insurance payment exceeds Medicaid rates, the excess is considered unearned income unless paid out on other medical services or supplies. Regardless of the existence of a good cause claim, any third party medical payment that is received directly by the recipient must be reimbursed.

Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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