Eligibility Corrective Action Participant Payments

PURPOSE: This rule establishes the basis on which participants may be reimbursed by the MO HealthNet program for Title XIX services and for services covered under state-only types of assistance programs and after this referred to as MO HealthNet paid by them to providers between the date of the initial agency decision denying their eligibility and the date of the agency or court decision establishing their eligibility for MO HealthNet. (1) All participants whose eligibility for MO HealthNet benefits is denied and whose eligibility is subsequently established as a result of an agency hearing decision, a court decision based on an agency hearing decision or any other final agency decision rendered on or after January 1, 1986 may be reimbursed by the MO HealthNet agency for MO HealthNet services paid by the participants to providers between the date of the agency decision denying their eligibility and the date of the agency or court decision establishing their eligibility for MO HealthNet benefits. (A) Payments to a participant will be made only for medical services which were covered services at the time provided in accordance with MO HealthNet program benefits, limitations and requirements applicable to the services or the participant as of the date provided, except that prior authorization requirements will not apply. (B) Payments may be made for services of either an enrolled MO HealthNet provider or for providers who do not participate in MO HealthNet. (C) Payments to a participant will be limited to the lesser of the MO HealthNet allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the participant for the covered item or service. (D) Any medical expenses paid by the participant which are for the purpose of meeting that participant’s spenddown obligation are not payable. (E) All third-party resource benefits received by the participant for MO HealthNet covered services must be applied against the lesser of the MO HealthNet allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the participant for the covered item or service. No payment shall be made to the participant until all third-party resource benefits have been exhausted as would have been applicable to participants receiving MO HealthNet. For purposes of this rule, neither the provider nor the participant shall be required to exhaust all thirdparty resources in those situations where the provider or the participant elects not to pursue contingent liability from a third-party tortfeasor. Both the provider and the participant have an affirmative duty to report the existence of contingent liability to the MO HealthNet Division and the participant has the duty to cooperate with the MO HealthNet Division if the division elects to pursue the contingent liability. (F) As evidenced by the MO HealthNet agency’s date of receipt, the participant or person legally responsible will have one (1) year from the date of the final agency or court decision establishing eligibility to submit all written requests for participant payment to the MO HealthNet agency with sufficient documentation to determine the appropriate reimbursement amount under the applicable provisions of subsections (1)(A), (C) and (E) for the MO HealthNet-covered items or services paid by the participant. AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2007.* This rule was previously filed as 13 CSR 40-81.141. Original rule filed April 16, 1985, effective Jan. 1, 1986. Amended: Filed Jan. 22, 1992, effective Sept. 6, 1992. Amended: Filed May 1, 2003, effective Nov. 30, 2003. Amended: Filed Oct. 12, 2007, effective April 30, 2008. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.