ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE

CHAPTER 560-X-33 RECOUPMENTS AND LIENS

TABLE OF CONTENTS

560-X-33-.01 General

560-X-33-.02 Purpose

560-X-33-.03 Methods

560-X-33-.04 Procedures

560-X-33-.05 Appeals

560-X-33-.01 General. Federal regulations require that the state make provisions for handling of recoupments and recoveries. The Alabama Medicaid Agency will actively seek recovery of all misspent Medicaid funds and correctly paid benefits recoverable under federal law.

Author:

Statutory Authority: Social Security Act; State Plan; Code of_Ala. 1975, 22-1-11, 22-6-8, 35-1-2; 42 C.F.R. Parts 431, 450, 455; 45 C.F.R. Parts 205; 233.

History: Rule effective October 1, 1982.

560-X-33-.02 Purpose. The purpose of the recoupments, recoveries and liens effort is to assure that the state and federal dollars allocated for medical assistance are spent only on those individuals who meet all eligibility criteria; to correct erroneous payments; and to recover benefits correctly paid, but recoverable by law. This mission will be fulfilled through solicitation of voluntary reimbursement and administrative and legal remedies in keeping with limitations set by federal guidelines.

Author:

Statutory Authority: Social Security Act, Title XIX; State Plan; 42 C.F.R. Parts 450, 455.

History: Rule effective October 1, 1982.

560-X-33-.03 Methods. Recoupment by the Alabama Medicaid Agency will be carried out using administrative procedures and civil and criminal proceedings to ensure that erroneous Medicaid payments are reimbursed and recoverable payments are collected. The methods may include but will not be limited to:

(a) Direct reimbursement by the recipient or his sponsor to the Alabama Medicaid Agency.

(b) Time payment by the recipient or by the sponsor on behalf of the recipient (if terms are acceptable to the Agency).

(c) Recovery of erroneous payments to providers through the fiscal agent from monies due those providers (to be used under special circumstances).

(d) Liens upon real property of recipients for recoverable benefits as permitted by federal law.

(e) Administrative sanctions on cases involving fraud or abuse of the Medicaid Program.

(f) Civil actions through the courts as deemed appropriate and approved by the Attorney General.

Author:

Statutory Authority: Social Security Act, Title XIX; State Plan; 42 C.F.R. Parts 450, 455; Code of Ala. 1975, 22-1-11, 22-6-8, 35-1-2; 45 C.F.R. Parts 233, 302.

History: Rule effective October 1, 1982.

560-X-33-.04 Procedures.

(1) Direct reimbursement. At the time of original identification of the expected amount of recoupment, a letter will be sent to the recipient/sponsor outlining the allegations and stating the amount of reimbursement and the specific dates when overpayment or recoverable benefits occurred. The recipient/sponsor will be offered the opportunity to present evidence to rebut the requirement for recoupment or to submit the reimbursement. If no rebuttal is offered, the original assessment will be presumed correct. Legal proceedings will be initiated in the event reimbursement is not received.

(2) Time Payment Plan. The reimbursement amount is due immediately. Upon sufficient justification, Alabama Medicaid Agency may allow a time payment plan. Under no circumstances will such payment schedule exceed two years.

(3) Fiscal Agent Recoupment. In the event the provider is the payee for the recipient (in effect, the sponsor) and has received the monies to be recouped, the excess payment will be withheld from the next adjustment payroll by the fiscal agent.

(4) Liens upon real property of recipients. Liens will be placed upon and foreclosed upon real property of recipients and deceased recipients to the extent allowed by 42 USC 1396(a)(18) and 42 C.F.R. 433.36.

(a) Where benefits have been incorrectly paid to or on behalf of a present or former recipient, the Agency after obtaining the concurrence of the Attorney General, may institute appropriate legal proceedings to obtain a judgement lien against that recipient or former recipient's property or estate; such liens will thereafter be enforced according to law.

(b) In the case of an individual who has received or is applying to receive benefits that are correctly paid due to the individual's being entitled to a temporary property or resource exclusion under the Agency's eligibility rule, the Agency may require said recipient to grant the Agency a lien by recording the same and, when appropriate, after obtaining the concurrence of the Attorney General, institute appropriate legal proceedings to obtain a judgement lien against that individual's property. Such lien may be obtained and secured by execution of a document substantially like Exhibit A, attached. (See Chapter 28 for a copy of the form to be used.) Such liens will become due, payable, and enforceable upon sale or transfer of lease for more than one year of said property, or upon death of grantor, and will otherwise be enforced in accordance with the provisions of 42 USC 1396(a)(18) as same may be amended by the Congress of the United States.

(c) The Agency may file claims against the estate of a deceased recipient who received benefits incorrectly, in accordance with existing law.

(d) The Agency may file a claim against the estate of a deceased recipient who correctly received benefits after the recipient was over 65 years of age (where the recipient's eligibility under Agency rules was due to a temporary property or resource exclusion). Enforcement of such claims will be subject to the provisions of 42 USC 1396(a)(18) as same may be amended by the United States Congress.

(e) If a recipient described in paragraphs (3) and (4) above dies intestate or is believed by the Agency to have died intestate, the Agency, after obtaining the concurrence of the Attorney General, in order to protect its right to file a claim against the deceased recipient's estate, may file a

petition for letters of administration in situations where the Agency's claim warrants the expense of administering the estate.

(5) Administrative sanctions. Cases involving apparent fraud and abuse of the Medicaid Program may be corrected with administrative sanctions within federal guidelines. Such sanctions may involve one or more years ineligibility from the Medicaid Program and until full restitution has been made.

(6) Civil Actions. Civil actions through the courts may be initiated on cases where the above procedures have not resulted in a satisfactory resolution.

(7) Criminal Actions. If there are strong indications of fraud and/or abuse of the Medicaid Program, cases will be referred to the appropriate authorities for prosecution.

Author: Arthur H. Miller

Statutory Authority: Social Security Act, Title XIX; State Plan; Code of Ala. 1975, 22-1-11, 22-6-8, 35-1-2; 42 C.F.R. 401, et seq., Parts 450, 455; 45 C.F.R. Parts 233, 302.

History: Rule effective October 1, 1982. Amended effective April 15, 1983.

560-X-33-.05 Appeals. Any person aggrieved by a proposed or actual recoupment action that is directed at that person can have the same reviewed through the Agency's fair hearing procedures if the matter has not previously been the subject of a Fair Hearing. A hearing must be requested within 60 days of the date of the notice of the recoupment action. A recoupment action will not be abated during the time for requesting a hearing. The Agency may at its discretion suspend a recoupment action until after a hearing is held.

Author:

Statutory Authority: 42 C.F.R. 401, et seq.; State Plan; Social Security Act, Title XIX.

History: Rule effective October 1, 1982.

EXHIBIT A

STATE OF ALABAMA

COUNTY OF

LIEN FOR MEDICAL PAYMENTS UNDER

ALABAMA MEDICAID PROGRAM

WHEREAS,________________________________________________,

("Medicaid Recipient")

is justly indebted to the Alabama Medicaid Agency ("the Agency") to the extent that the Agency has paid medical benefits for Medicaid Recipient under the Alabama Medicaid Program ("the Program"); and

WHEREAS, Medicaid Recipient may hereafter become indebted to the Agency to the extent that the Agency pays future medical benefits for Medicaid Recipient;

NOW, THEREFORE, in order to secure the repayment of said indebtedness and in order for Medicaid Recipient to obtain medical benefits under the Program, the Medicaid Recipient, joined by (his)(her) spouse does hereby GRANT, BARGAIN, SELL, ASSIGN and CONVEY unto the Agency, its successors and assigns, a lien for the full dollar value of said medical benefits paid and to be paid, on the following described real estate situated in __________________________County, Alabama, to-wit:

Subject, however, to all existing liens now on said property.

Notice of this lien will be recorded in said county and the dollar value of this lien as it may exist from time to time, may be obtained by writing to: Commissioner, Alabama Medicaid Agency, 2500 Fairlane Drive, Montgomery, AL 36130. This lien shall be due and payable upon the sale, transfer or lease of said property, or upon the death of Medicaid recipient, and shall otherwise be enforceable in accordance with the limitations of 42 USCA 1396a(18) as the same may be amended.

IN WITNESS WHEREOF, the undersigned (has) (have) duly executed this instrument to voluntarily grant the aforesaid lien on this the_____day of________________, 19___.

________________________________ ___________________________

Spouse Medicaid Recipient

Witness:_______________________

STATE OF ALABAMA

COUNTY OF

I, the undersigned, a notary public in and for said state and county, hereby certify that _____________________________,

whose name as an Alabama Medicaid recipient, a (single) (married) person, is signed to the foregoing instrument, and

____________________ (his)(her) spouse, whose name is also signed to said instrument, acknowledged before me on this day that being informed of the contents of said instrument (they)(he)(she) executed the same voluntarily on the day the same bears date.

Given under my hand and official seal this the __________

day of_______________, 19____.

(SEAL) __________________________

Notary Public