SR 94-31 Dated 08/94

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases a clarification of policy on co-payments and donations for services which could be provided under the Medicaid HCBC-ECI program but are, instead, reimbursed by another funding mechanism such as the Social Services Block Grant. It clarifies Medicaid Provider Agreements on this subject, including the application of those agreements to HCBC-ECI Home Health Services; and it clarifies policy on this subject in Adult Assistance Manual (AAM) Part 621.

BACKGROUND

In the fall of 1993, Attorney General’s Medicaid Fraud Control Unit, now under the Department of Justice, advised the Division of Human Services and the Division of Elderly and Adult Services that Medicaid regulations, which prohibit seeking co-payments from HCBC recipients, apply whether or not Medicaid is the actual source of reimbursement. While these rules clearly allow a HCBC service provider to accept reimbursement from a third party or parties (usually insurance) which reimburse at higher rates than does Medicaid for Medicaid covered HCEC services, they clearly prohibit the provider from seeking a contribution or co-payment from the HCBC recipient. The Medicaid Fraud Control Unit interprets these regulations to mean that if a HCBC recipient receives a service which could have been covered by Medicaid, whether or not Medicaid is the source of payment, he or she is entitled to the service without additional cost through either a co-payment or a donation.

The Medicaid Fraud Control Unit has further clarified that entitlement to HCBC services without a co-payment or donation applies only to the specific service which could have been reimbursed by the Medicaid Program. If the particular service is not available to the recipient under the Medicaid Program, there is no legal prohibition to seeking a co-payment or contribution for the service.

POLICY

Medicaid enrolled providers are prohibited from billing HCBC-ECI recipients for co-payments or donations when non Medicaid reimbursement has been made for services which could have been provided under the Medicaid HCBC program.

• Home health services for HCBC-ECI recipients

Providers of HCBC-ECI home health services who have agreed to accept the Medicaid payment in full by enrolling as Medicaid providers are bound by the agreement and may not request a contribution for HCBC-ECI services. When a plan of care is developed which contains a service covered under the Title XIX Medicaid State Plan and under Title XX or Title III, case managers may elect the funding source(s). However, no enrolled provider of such services may seek contribution from the recipient.

• Adult Assistance Manual Part 621

Recipient co-payments and donations may still be deducted from the client's contribution to the cost of care, as specified in AAM, Part 621, if:

1. The medical service is not a Medicaid covered service; or

2. the Provider is enrolled, but not as a provider of the specific service.

PROCEDURE CHANGES

There are no changes in procedures relative to the policy clarification released in this SR.

SYSTEM CHANGES

There are no system changes relative to the policy clarification released in this SR.

IMPLEMENTATION

The case manager will discuss this policy with the recipient as part of the application process or during other contacts, if the recipient is affected by the policy.

CLIENT/PROVIDER NOTIFICATION

Providers of HCBC-ECI home health services will be notified by a Provider Bulletin. Case Managers will discuss and explain this issue as part of the new application process or during other contacts with any impacted recipient.

TRAINING

No training is planned. Questions may be-addressed to OMS Client Services.

MANUAL CHANGES

There are no manual page changes relative to the policy clarification released in this SR.

DISPOSITION

Please retain this SR in front of ITEM 952, "Home and Community-based Care for the Elderly and Chronically Ill," of the Medical Assistance manual.

DISTRIBUTION

This SR is being distributed according to the narrative SR distribution list of holders of the Medical Assistance and Adult Assistance Manuals, to all heads of DHS and DEAS organizational units, to all District Office Regional Administrators, to all case managers, and to all OMS/LTC staff.

LB/CHC