Revision 13-1; Effective March 1, 2013

 

H-8100 Co-Payment Corrections

Revision 12-4; Effective December 1, 2012

 

Service Authorization System Online (SASO) reflects future co-payment amounts. These amounts are based on the amount of each individual's income that is reported.

If a recipient is living in a long-term care facility other than a state supported living center or a state center, use Form H1259, Correction of Applied Income, to correct co-payment amounts in TIERS.

Note: The nursing facility is required to refund co-payment overcharged to the recipient. Reconciliation does not apply to home and community based waivers or assisted living facilities.

 

H-8110 Adjustments from Income Averaging

Revision 12-1; Effective March 1, 2012

 

When income is averaged, review the case at least every six months and reconcile the budget according to the monthly income actually received. If both the projected average income and the actual monthly income are each less than $2, or if the difference between the two is less than $1, then reconciliation is not required. If co-payment must be increased or decreased because of income averaging, use Form H1259, Correction of Applied Income, to correct retroactive periods. Notify the recipient about the correction to co-payment. Send copies of this notice and Form H1259 to the nursing facility. For ongoing adjustments, submit through the automated system.

Note: Make corrections in the Service Authorization System Online (SASO).

Although reconciliation is not required for certain small amounts, reconcile whenever the recipient requests it.

If the variable income adjustment is a positive number (the recipient underpaid co-payment), add the adjustment to the co-payment for the most recent month in the reconciliation period.

Example: If reconciling the period of October through March, the most recent month in the reconciliation period is March. Form H1259 is sent to the recipient and nursing facility, and after 12 days the co-payment is adjusted in SASO in the most recent month.

There is no month-by-month adjustment in the reconciliation period (October-March) in SASO for this underpayment. Page 2 of Form H1202-A, MAO Worksheet – Income Changes, may be used to assist in calculating the correct reconciliation period and the most recent month in the reconciliation period.

 

H-8120 Other Adjustments

Revision 12-3; Effective September 1, 2012

 

When adjustments for retroactive periods are needed for reasons other than to reconcile for income averaging, use the following procedures:

For MEPD cases, use Form H1259, Correction to Applied Income, only to report retroactive decreases in a recipient's co-payment. If the recipient's correct co-payment is more than that reported on the Service Authorization System Online (SASO) see H-8200, Procedures Relating to Overpayments, through H-8230, Cases Not Submitted for Prosecution. To update a recipient's co-payment for future months, process through the automated system. The effective date of the change shown in SASO is based on the effective date of the disposition action in the automated system.

For SSI cases, use Form H1259 to report any changes in co-payment. Increases in co-payment are effective the first day of the month after the date Form H1259 is completed. If the recipient's correct co-payment is more than that reported on SASO, use procedures in H-8200. The procedures for correcting co-payment do not apply to cases of fraud. In conducting a review or verifying co-payment, do not submit Form H1259 if fraud is indicated. Follow fraud procedures outlined in the Fair and Fraud Hearings Handbook.

 

H-8200 Procedures Relating to Overpayments

Revision 10-1; Effective March 1, 2010

 

 

H-8210 Willful Withholding of Information

Revision 10-1; Effective March 1, 2010

 

In the Medicaid program, fraud means deliberate misrepresentation or willful withholding of information for the purpose of obtaining public assistance, either for self or another individual.

Clearly indicate willful withholding of information that affects eligibility or the amount of co-payment. Do not accuse recipients of fraud.

Reference: For further explanations of fraud referral procedures, refer to the Fair and Fraud Hearings Handbook.

Willful withholding of information includes:

  • willful misstatements, oral or written, made by a recipient or authorized representative in response to oral or written questions from the department concerning the recipient's income, resources or other circumstances that may affect the amounts of benefits. These misstatements may include understatements or omission of information about income and resources.
  • willful failure by the recipient or authorized representative to report changes in income, resources or other circumstances that may affect the amounts of benefits, if the department has clearly notified the recipient or authorized representative of his obligation to report these changes.

When a recipient or authorized representative signs the application/review form, he certifies that he understands that failure to fulfill his obligation to provide correct, complete information and to keep the department informed of changes may be considered willful withholding of information. Because of this willful withholding of information, the department is allowed to recover the overpayments.

 

H-8220 Overpayments Resulting from Suspected Fraud

Revision 10-1; Effective March 1, 2010

 

In cases of suspected fraud, follow these steps:

Step Procedure
1 Certify continued assistance in the correct amount or deny the case. Observe notification of adverse action and appeal procedures.
2 To report waste, abuse or fraud, please use the HHSC online reporting form at oig.hhsc.texas.gov, TIERS, GWS or call toll-free 1-800-436-6184.
3 Complete periodic and special reviews while the case is investigated for suspected fraud. Contact the Investigations Division to determine whether the periodic review may cause problems or advise them of changes in circumstances. Example: The authorized representative who is suspected of willfully withholding information dies after the report is submitted to the Investigations Division. Contact the Investigations Division and advise them of the individual's death.

 

H-8230 Cases Not Submitted for Prosecution

Revision 10-1; Effective March 1, 2010

 

If the prosecuting attorney or the investigator determines that the case is not suitable for prosecution, the investigator tries to arrange a voluntary plan of restitution.

If the investigator does not arrange repayment, the MEPD staff is informed that the case not presented for prosecution and no plan of repayment arranged. Seek restitution for the amount of overpayment.

If the investigative unit does schedule repayment, you will be notified via Form H1018, Overpayment Claim. Seek restitution for the amount of the uncollected overpayment.

 

H-8300 Restitution

Revision 10-1; Effective March 1, 2010

 

 

H-8310 Restitution Defined

Revision 12-4; Effective December 1, 2012

 

Restitution is securing payment from a recipient when fraud is not indicated or pursued and when the recipient has been undercharged co-payment because of previously unreported or under-reported monthly income or resources that do not involve income averaging.

Restitution applies only to recipients in intermediate and skilled nursing facilities and in community-based ICF/IID facilities. The department does not seek restitution from recipients or recipients' authorized representatives for vendor payments made to state supported living centers or state centers. The department does not seek restitution from recipients or recipients' authorized representatives on home and community based waiver cases, including those living in assisted living facilities.

 

H-8320 Restitution Procedures

Revision 12-1; Effective March 1, 2012

 

Recipients or responsible relatives for recipients must notify the department within 10 calendar days of changes in income, resources and other circumstances that affect the amount of benefits received. Any department employee who receives or obtains information from or about a recipient is responsible for relaying the information immediately to the appropriate eligibility specialist. If a recipient has been undercharged co-payment because of previously unreported or under-reported monthly income or resources that do not involve income averaging, and fraud is not indicated, pursue voluntary restitution. Discuss the situation with the recipient and send Form H1225, Restitution. Record restitution requests in case comments.

Calculate the amount of restitution based on the difference between the correct daily co-payment and the previously collected daily co-payment. Multiply this amount by the number of days the recipient was in the facility. For months in which a recipient was ineligible, the amount of restitution sought is the total amount of vendor payments made by the department for those months. Include the reason for the restitution request on Form H1225.

With the following exception, do not request restitution for the current month until the month is over. If ineligibility is a result of resources on hand and the recipient will be ineligible until resources are reduced, restitution may be requested for a current month.

Overpayments of restitution are refundable from Fiscal Management Services.

 

H-8330 Overpayments Considered for Restitution

Revision 13-1; Effective March 1, 2013

 

HHSC pursues restitution for MEPD and SSI cases if the overpayment is not the result of department error or income averaging and any of the following situations occur:

  • Actual income received in any month varies by $5 or more from budgeted income.
  • Fraud is suspected and cumulative vendor payment does not exceed $100.

Note: If the difference between the actual and projected income is the result of income averaging and you are submitting Form H1259, Correction of Applied Income, do not pursue restitution. However, if the budget must be corrected for both income averaging and a lump-sum payment, reconcile the averaged income and seek restitution for the lump-sum payment.

  • Changes in income were not reported within 10 days from receipt. Restitution is requested beginning with the month the increased income was received.
  • A lump-sum payment (including income excluded for eligibility as irregular or infrequent income) raises income more than $5 for any month.
  • Initial payment plan (co-payment) for an SSI recipient is understated by $5 or more.
  • A recipient is advised about the correct amount of co-payment on the appropriate notification form, but a lower amount appears on the Patient Status Payment Plan Notice because of a processing or coding error.
  • A recipient is determined to be ineligible for the month because of unreported or under-reported resources that exceed program limits.
  • ICF, SNF or ICF/IID vendor payments have been continued for a denied recipient pending an appeal, and the hearing officer upholds the denial. Seek restitution for the total amount of the vendor payment made between the initial denial effective date and the date payment stops after the hearing decision. If payments are discontinued because the recipient is denied a level of care, the department requests restitution for vendor payments made after the original level-of-care denial date (as shown on Texas Department of State Health Services Form X-27).
  • Co-payment has been continued at a lower level pending an appeal of an increase, and the hearing officer sustains the increase. Seek restitution for the difference between the old and new co-payment amounts for the period from the effective date of the original increase until the date of the appeal decision.
  • Income tax refunds are subject to restitution policy (in the month of receipt) for co-payment purposes to the extent that withholding tax was excluded in the co-payment budget.

 

H-8340 Overpayments Not Considered for Restitution

Revision 09-4; Effective December 1, 2009

 

HHSC does not seek restitution for MEPD and SSI cases in any of the following situations:

  • Cumulative overpayment is $5 or less (for any month).
  • Overpayment of over $100 is referred for fraud.
  • Overpayment is the result of the department's computation error or failure to act on available information.
  • A change in regular monthly income (not lump-sum payment) is reported within 10 days of receipt. The department does not seek restitution for the month of receipt or for the subsequent month if the 10-day advance notice period extends beyond the department's computer cutoff date for that month.
  • Income is incorrect as a result of an automated across-the-board adjustment.
  • The resource limitation was met on the first day of the month. If a recipient's resources exceed the limit during the month, the department does not collect restitution for partial months.
  • Co-payment is based on income averaging.

 

H-8350 Steps for Submitting Restitution Payment

Revision 09-4; Effective December 1, 2009

 

Step Procedure
1 Obtain the recipient's cashier's check, money order or personal check in whole dollar amounts made payable to the Texas Department of Aging and Disability Services.
2 Give the recipient the original Form H4100, Money Receipt.
3 Attach the first copy of Form H4100 to the payment, and send to:

Provider Claims Payment Services
Mail Code E-400
Department of Aging and Disability Services
P.O. Box 149081
Austin, TX 78714-9081
4 Record the payment on the worksheet.

Note: Submit payments to Provider Claims Payment Services on the day of receipt.

 

H-8360 Steps for Requesting a Refund of Restitution Overpayment

Revision 09-4; Effective December 1, 2009

 

If an incorrect amount of restitution is collected because the recipient was not in the facility for the full month, refunds of more than $1 are requested from Provider Claims Payment Services.

To request a refund:

 

Step Procedure
1 Determine and document the amount of the refund on the worksheet.
2 Send a memo to:

Provider Claims Payment Services
Mail Code E-400
Department of Aging and Disability Services
P.O. Box 149081
Austin, TX 78714-9081
  • Include the following information:
    • date of restitution payment and Form H4100 receipt number,
    • amount of refund due,
    • name of the recipient, and
    • recipient's Social Security number.
  • Request a copy of voucher for case record