PM 01-07-12-b: Medical Benefits

WAG 01-07-12-b.

For medical benefits, carry out the decision immediately, but no later than 90 days after the date the appeal was filed unless the appellant asked for a delay.

DHS arranges for HFS to reimburse clients for paid medical bills when directed by an appeal decision. A client may be reimbursed for paid medical bills when it is determined through the appeal process that:

  • an application was denied in error and was later found eligible; or
  • a case was canceled in error and assistance was restored; or
  • a case should have been regular medical or cash, but was in spenddown status (met or unmet); or
  • the spenddown amount was incorrectly determined to be too large and the case currently is not in spenddown status (is canceled, or is regular medical or cash).

In order to get reimbursed:

  • the client must have appealed a DHS or HFS decision; and
  • the decision must be determined to be incorrect, either at the pre-hearing level or in an appeal decision; and
  • the client must have paid medical bills that could have been paid by HFS for the time period in question; and
  • the case must not currently be in spenddown status.

HFS limits reimbursement to clients for paid bills that are eligible for Medicaid payment. Reimbursement will not be made to clients for paid medical expenses when the client is still in spenddown status.

Example 1: Client has a $100 spenddown amount and pays $75 for medical care. Appeal decision determines the client should not have a spenddown. Case is no longer in spenddown status. Client is entitled to reimbursement for the $75 payment.

Example 2: Family Community Resource Center determines client has a $100 spenddown. Client pays $75 for medical care. An appeal decision determines the spenddown amount should have been $50. The case is still in spenddown status. Client is not entitled to reimbursement. Client can apply the $75 toward the $50 spenddown for the current or future months.