WAG 17-03-03-a

If DHS and HFS make timely decisions on less than 96% of the medical benefits applications received during a month, the State must reimburse qualifying applicants for covered medical expenses they paid or someone paid for them.

A person qualifies for reimbursement if DHS and HFS failed to meet the 96% standard for the month in which their application was approved and:

  • they are determined eligible for medical benefits after the time limits because of a DHS or HFS delay; and
  • they paid for, or had someone pay for them, covered medical expenses; and
  • the paid medical expenses were incurred after the application date; and
  • the medical expenses were paid between the first day the pending application exceeded the time limit and the day the approval notice was mailed.

In addition, a long-term care resident may be entitled to reimbursement if DHS did not send a timely approval for billing.