Reimbursement of Certain Clients for Out-of-pocket Expenses

(A) Requirements. The following individuals shall be entitled to reimbursement by MassHealth for certain medical expenses: (1) An individual who: (a) was denied SSI benefits by the Social Security Administration (SSA); and (b) the initial SSA decision was overturned through the reconsideration process, administrative hearing, Appeals Counsel review, Federal Court review, or reopening under SSA rules on administrative finality. (2) An individual who: (a) was denied TAFDC benefits by the Department (DTA); and (b) has had his or her initial DTA decision overturned by a subsequent decision by DTA, DTA's fair hearing process, or the judicial review process. Reimbursement is limited to bills that are incurred on or after the date of initial MassHealth eligibility, and that are paid between the date of the erroneous application decision and the date on which the client is notified of MassHealth eligibility. The bill must have been paid by the client or spouse, or the parent or legal guardian of a minor client. Reimbursement under 106 CMR 705.160 is for amounts actuallypaid for care or services that would have been covered under MassHealth had eligibility been determined correctly even though those amounts may exceed the MassHealth rate. Prior to reimbursing a client for care or services that would have needed prior approval, the Department may require that the client submit medical evidence for consideration under the prior approval standards. Reimbursement is available even though the medical care or services were furnished by a provider who does not participate in MassHealth. (B) Verification. Persons asking for reimbursement must provide MassHealth with: (1) A bill for medical services that includes: (a) the provider's name; (b) a description of the services provided; and (c) the date the service was provided; and (2) Proof of payment of the bill presented, such as a canceled check or receipt. SSI clients must also provide documents from the Social Security Administration establishing the dates of application and denial.