Sneak Preview: Calif. Fails To Meet Redetermination Deadlines

August 18, 2011 | By Jerry Ashworth | Post a Comment

(This post is based on an upcoming article in the Federal Grants Management Handbook.) States must understand the time limits for receiving Medicaid reimbursement for newly ineligible beneficiaries because making claims for an extended period may not be allowed.

The Department of Health and Human Services Departmental Appeals Board sustained a Centers for Medicare and Medicaid Services disallowance of about $12.3 million in Medicaid expenditures made from April 2003 to September 2004 by the California Department of Health Care Services. The disallowed expenditures were for services provided to individuals who had originally been identified by the state as eligible for Medicaid  because they had received supplemental security income payments from the Social Security Administration, but were later found to be ineligible for SSI.

Medicaid reimbursement is only available for individuals for a limited time after SSA informs a state that they are ineligible, unless the state determines that they are eligible for Medicaid on another basis. CDHCS, however, continued to claim Medicaid reimbursement for expenditures beyond the applicable time limits, even though the agency had not made any new eligibility determinations. CMS and the appeals board rejected the agency’s argument that it was entitled to an exception due to a court order.

More information about the case and the appeals board’s response is available in the September issue of the Federal Grants Management Handbook.


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