Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 20 - Division of County Operations › Rule 016.20.96-021 - Changes to the Medical Services Policy Regarding Children Under the Age of 19

Current through Register Vol. 49, No. 6, June, 2024
MS. 1345.4
To apply for a waiver, the representative or distributee must
				mail a statement to the Office of Chief Counsel, Attention: Decedents' Estates,
				P. 0. Box 1437, Slot 1033, Little Rock, AR 72203-1437, setting forth the facts
				which constitute the undue hardship. Tax returns, income statements or other
				documents which support the position that estate recovery would work an undue
				hardship on the survivors may be submitted.
A determination that hardship does not exist will be made if
				the individual created the hardship through estate planning in which assets
				were divested in order to avoid estate recovery,
A decision on the hardship waiver will be made by a DHS Central
				Office Committee within 30 days of receipt of the waiver request.
The DHS decision will be sent by certified mail, return receipt
				requested, to the person who applied for the waiver.
If recovery is not made due to a determination of hardship, DHS
				may decide to recover at a later time if the conditions which caused the
				original hardship cease to exist.
1345.5
Appeal Rights
The waiver applicant may appeal the DHS decision regarding the
				hardship waiver by writing to the Office of Appeals and Hearings and requesting
				an administrative review of the decision. The request must be received no later
				than 30 days from the date of the notice of negative action.
1348
Inmates of Public
			 Institutions
An inmate of a public institution is not eligible for
				Medicaid.
Federal regulations at
				42 CFR
				435.1009 define a public institution as an
				institution that is the responsibility of a governmental unit or over which a
				government unit exercises administrative control. This control can exist when a
				facility is actually an organizational part of a government unit, or when a
				governmental unit exercises final administrative control. Public institutions
				include county jails, state and federal penitentiaries, juvenile detention
				centers, and other correctional or holding facilities. Wilderness camps
				and_boqt camps are "considered public institutions if a governmental unit has
				any degree of administrative control.
Federal regulations at
				42 CFR
				435.1009 define an inmate as an individual
				living in a public institution.
An individual who is an inmate in a penal or correctional
				institution is not Medicaid eligible, because the State or other governmental
				authority, by the act of incarceration, has assumed full responsibility for
				his/her care. If the inmate must be temporarily transferred to a medical
				treatment or evaluation facility, or if he/she is given temporary furlough, the
				individual is still considered an "inmate" under custody of the penal or
				juvenile justice system and is excluded from the Medicaid program.
Inmate status will continue until the indictment against the
				individual is dismissed or until he/she is released from custody either as "not
				guilty" or for some other reason (bail, parole, pardon, suspended sentence,
				home release program, probation, etc.).
1350
Mandatory Assignment of
			 Rights to Medical Support/Third Party Liabilities
As a condition of eligibility for Medicaid, recipients are
				required to assign their rights to Medical Support/Third Party Liability
				payments to the Division of Medical Services. This means that any funds
				settlements, or other payments made by or on behalf of third parties should be
				paid directly to the Arkansas Medicaid Program. In Arkansas, Third Party
				Liability payments are automatically assigned by state law.
The Medical Assistance Program is required by Federal and State
				Regulations to utilize all Third Party sources and to seek reimbursement for
				services which have been paid by both a Third Party and Medicaid.
Private insurance and Medicaid are complementary. A recipient's
				Medicaid eligibility is not affected by having Third Party coverage.
When a recipient has Third Party coverage in addition to
				Medicaid which can be used for medical expenses, Third Party coverage must be
				utilized first. Medicaid will pay up to the Medicaid allowable charge. For
				example: A Medicaid recipient has insurance which paid 80%, or $80 of a $100
				medical bill. The Medicaid allowable charge for the bill was only $60.00. A
				Medicaid payment was not due since the.Medicaid allowable charge was less than
				the insurance payment. Third Party sources whose payment Medicaid will retrieve
				include private health insurance, automobile liability insurance where
				applicable, workmen's compensation, settlements for injuries, etc.
The Civilian Health and Medical Program of the Uniformed
				Services (CHAMPUS) is considered to be a Third Party source. Whenever a CHAMPUS
				beneficiary is also eligible for Medicaid, CHAMPUS is in
ewery
instance the primary payor. This applies to all classes of CHAMPUS
				beneficiaries, i.e., dependents of active duty members, retirees, dependents of
				retirees, dependents of deceased active duty members, and dependents of
				deceased retirees.
1350.1
County Office Responsibility
Third Party resources (if any) will be determined by completing
				the DCO-662 at the time of application and at each reevaluation when Third
				Party coverage is reported by the applicant/recipient. Third Party resources
				will be indicated on the'DCO-56 or DCO-57, whichever is applicable.
Third Party information will be indicated on the TPL field on
				the DCO-56 or DCO-57 and consists of an alpha code. Refer to forms instructions
				for the applicable code.
NOTE: For cases involving CHAMPUS, the name and Social Security
				Number of the service member must be entered on the DCO-662. The CHAMPUS
				address is P.O. Box 7938, Madison, WI 53707.
Upon determining that Third Party coverage exists, inform the
				recipient of the restrictions placed on the coverage by the Medicaid Program,
				(i.e., recipients are not entitled to any benefits and/or compensation from
				Third Party sources on services for which Medicaid has made or will make
				compensation). Instruct recipients who want Medicaid billed for services that
				they are to assign their TPL resource benefits to the provider before services
				are rendered.
1350.2
Recipient Responsibility
Recipients are not entitled to any benefits and/or compensation
				from Third Party sources on services for which Medicaid has made or will make
				compensation. For this reason, recipients are responsible for assigning the TPL
				resource benefits to the provider before services are rendered if they want
				Medicaid billed for the services.
If the provider elects not to accept Medicaid on the recipient,
				the recipient becomes a "private pay" patient and is responsible for the full
				cost of services rendered. Assignment is not required for non-Medicaid
				claims.
1350.3
Provider Responsibility
It is the responsibility of the provider to be alert to the
				possibility of Third Party sources, to file a claim for services with Third
				Party sources, and to report receipt of funds from these sources to the Medical
				Assistance Section.
Since Medicaid makes payment on a "last pay" basis, the
				provider has the option of accepting the private insurance payment or that of
				Medicaid. When both the private insurance and Medicaid make payment, the
				provider can keep the larger of the two payments but must refund the lesser
				amount to Medicaid,
1350.4
Procedure for Failure to Cooperate
Recipients who are not cooperating with the Division of Medical
				Services Third Party Liability Unit will be subject to termination of Medicaid
				assistance. The Third Party Liability Unit will notify the County Office when a
				recipient has been determined uncooperative.
When a notice is received from the Third Party Liability Unit
				that a recipient is not cooperating, the Service Representative will:
1. Complete Form DCO-700 to give advance
			 notice to the recipient that his Medicaid will be terminated due to failure to
			 cooperate.
2. For single member
			 cases, complete DCO-57 to process a close action, effective the date advance
			 notice expires. Use code 059 for this action.
3. For family Medicaid cases,' complete an
			 other "0" action on Form DCO-56,
using action reason 003 and close the adult member on WAFM
				effective the date advance notice expires. Use code 059 to close an adult
				member.
If the adult has countable income used in determining
				eligibility, key a "Y" to the Budget Indicator Field.
4. For AFDC Grant or No-Grant cases, complete
			 Form DCO-56 to enter the Medicaid End Date for the adult member only. Leave the
			 adult member status open so that the adult's needs will continue to be included
			 in the case,
The recipient who has not cooperated with the Third Party
				Liability Unit will remain ineligible for Medicaid until that unit determines
				that the recipient is cooperating. The Third Party Liability Unit will notify
				the County Office when a case or member can be reopened.