Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.040 - Eligibility Corrective Action Participant Payments

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes the basis on which
				  participants may be reimbursed by the MO HealthNet program for Title XIX
				  services and for services covered under state-only types of assistance programs
				  and after this referred to as MO HealthNet paid by them to providers between
				  the date of the initial agency decision denying their eligibility and the date
				  of the agency or court decision establishing their eligibility for MO
				  HealthNet.
(1) All
				participants whose eligibility for MO HealthNet benefits is denied and whose
				eligibility is subsequently established as a result of an agency hearing
				decision, a court decision based on an agency hearing decision or any other
				final agency decision rendered on or after January 1, 1986 may be reimbursed by
				the MO HealthNet agency for MO HealthNet services paid by the participants to
				providers between the date of the agency decision denying their eligibility and
				the date of the agency or court decision establishing their eligibility for MO
				HealthNet benefits.
(A) Payments to a
				participant will be made only for medical services which were covered services
				at the time provided in accordance with MO HealthNet program benefits,
				limitations and requirements applicable to the services or the participant as
				of the date provided, except that prior authorization requirements will not
				apply.
(B) Payments may be made for
				services of either an enrolled MO HealthNet provider or for providers who do
				not participate in MO HealthNet.
(C) Payments to a participant will be limited
				to the lesser of the MO HealthNet allowable amount for the covered item or
				service as of the date provided or the aggregate amount paid by the participant
				for the covered item or service.
(D) Any medical expenses paid by the
				participant which are for the purpose of meeting that participant's spenddown
				obligation are not payable.
(E) All
				third-party resource benefits received by the participant for MO HealthNet
				covered services must be applied against the lesser of the MO HealthNet
				allowable amount for the covered item or service as of the date provided or the
				aggregate amount paid by the participant for the covered item or service. No
				payment shall be made to the participant until all third-party resource
				benefits have been exhausted as would have been applicable to participants
				receiving MO HealthNet. For purposes of this rule, neither the provider nor the
				participant shall be required to exhaust all third-party resources in those
				situations where the provider or the participant elects not to pursue
				contingent liability from a third-party tortfeasor. Both the provider and the
				participant have an affirmative duty to report the existence of contingent
				liability to the MO HealthNet Division and the participant has the duty to
				cooperate with the MO HealthNet Division if the division elects to pursue the
				contingent liability.
(F) As
				evidenced by the MO HealthNet agency's date of receipt, the participant or
				person legally responsible will have one (1) year from the date of the final
				agency or court decision establishing eligibility to submit all written
				requests for participant payment to the MO HealthNet agency with sufficient
				documentation to determine the appropriate reimbursement amount under the
				applicable provisions of subsections (1)(A), (C) and (E) for the MO
				HealthNet-covered items or services paid by the participant.