PURPOSE: This rule establishes the basis on which recipients may be reimbursed by the Medicaid program for Title XIX services and for services covered under state-only types of assistance programs and after this referred to as Medicaid 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 Medicaid.

1. (1) All recipients whose eligibility for Medicaid 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 Medicaid agency for Medicaid services paid by the recipients 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 Medicaid benefits.

   1. (A) Payments to a recipient will be made only for medical services which were covered services at the time provided in accordance with Medicaid program benefits, limitations and requirements applicable to the services 13 CSR 70-4

or the recipient as of the date provided, except that prior authorization requirements will not apply.

1. (B) Payments may be made for services of either an enrolled Medicaid provider or for providers who do not participate in Medicaid.
2. (C) Payments to a recipient will be limited to the lesser of the Medicaid allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the recipient for the covered item or service.
3. (D) Any medical expenses paid by the recipient which are for the purpose of meeting that recipient’s spenddown obligation are not payable.
4. (E) All third-party resource benefits received by the recipient for Medicaid-covered services must be applied against the lesser of the Medicaid allowable amount for the covered item or service as of the date provided or the aggregate amount paid by the recipient for the covered item or service. No payment shall be made to the recipient until all third-party resource benefits have been exhausted as would have been applicable to recipients receiving Medicaid. For purposes of this rule, neither the provider nor the recipient shall be required to exhaust all third-party resources in those situations where the provider or the recipient elects not to pursue contingent liability from a thirdparty tortfeasor. Both the provider and the recipient have an affirmative duty to report the existence of contingent liability to the Division of Medical Services and the recipient has the duty to cooperate with the Division of Medical Services if the division elects to pursue the contingent liability.
5. (F) As evidenced by the Medicaid agency’s date of receipt, the recipient 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 recipient payment to the Medicaid agency with sufficient documentation to determine the appropriate reimbursement amount under the applicable provisions of subsections (1)(A), (C) and (E) for the Medicaid-covered items or services paid by the recipient.

AUTHORITY: sections 208.153 and 208.201, RSMo 2000.* This rule was previously filed as 13 CSR 40-81.141. Original rule filed April 16, 1985, effective Jan. 1, 1986. Amended: Filed Jan. 22, 1992, effective Sept. 6, 1992. Amended: Filed May 1, 2003, effective Nov. 30, 2003. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.