La. Admin. Code tit. 50 § I-8103

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8103 - General Provisions

A. Medicaid estate recovery is not a condition of eligibility. The applicant/recipient shall be informed at the time of application/redetermination that federal law and regulations mandate estate recovery action by the states and that medical assistance claims paid by the department may be subject to estate recovery. A notice of estate recovery is provided to the applicant as part of the application process.

B. Recovery Limits

1. Recovery can only be made after the death of the recipient's surviving spouse, if any, and only at the time when the recipient has no surviving child under age 21, or a child who is blind or disabled as defined in Section 1614 of the Social Security Act. Recovery may be deferred until the death of the surviving spouse or children reach the age of 21 or are no longer blind or disabled.

2. Recovery cannot be made for Medicare cost-sharing benefits (i.e., Part A and Part B premiums, deductibles, coinsurance, and co-payments) paid under the Medicaid State Plan.

C. Recovery Adjustments

1. Recovery may be waived in cases in which it is not cost-effective for the state to recover from the recipient's estate.

2. Recovery shall be waived if it will cause an undue hardship on any child of the deceased recipient.

3. The recovery may be lessened by reducing the estate value in consideration of reasonable and necessary documented expenses incurred by the decedent's heirs to maintain the homestead during the period in which the recipient was in a long term care facility or received home and community-based services, if the homestead is part of the estate.

D. Recovery Notice

1. The department will seek recovery for medical assistance from the decedent's estate. The family or heirs will be given advance notice of the proposed action and the time frame in which they have the opportunity to apply for an undue hardship waiver and/or dispute the recovery.

2. A notice of Medicaid estate recovery will be served on the executor, authorized representative or succession attorney of the decedent's estate. If there is no executor, authorized representative or succession attorney, the notice will be sent to the family or the heirs. The notice shall specify the following information:

a. the deceased recipient's name and Medicaid identification number;

b. the action the state intends to take;

c. the reason for the action;

d. the dates of services associated with the recovery action and the estimated amount of the department's claim, i.e., amount to be recovered against the recipient's estate;

e. the right to and procedure for applying for a hardship waiver;

f. the authorized representative's right to a hearing;

g. the method by which the authorized representative may obtain a hearing; and

h. the time periods involved in requesting a hearing or in exercising any procedural requirements under the Medicaid Estate Recovery Program.

3. The notice shall request that copies of all succession pleadings filed in connection with the succession of the decedent, including any judgment(s) of possession be provided to the department.

a. In the event no succession has been judicially opened, the department is to be advised as to when such documents will be available and/or when the succession is expected to be opened.

E. Recovery Privilege

1. The claim of the department shall have a privilege on the total estate with a priority equivalent to an expense of last illness as prescribed in Civil Code Article 3252 et seq.

2. The department may file a proof of claim based on its privilege.

F. Recovery Exclusions

1. If an individual was insured under a qualifying long-term care insurance partnership policy and received Medicaid benefits as a result of resources being disregarded in the eligibility determination, the department shall not seek adjustment or recovery from the individual's estate for the amount of the resources disregarded.

a. The resource disregard is determined on a 1:1 ratio. For each $1 of a qualifying long-term care insurance partnership policy benefit, $1 of countable resources is disregarded or excluded during the eligibility determination process.

2. The department shall not seek recovery or adjustment from an individual's estate for the amount of Medicare cost-sharing benefits paid on behalf of an individual that was enrolled in any one of the following Medicaid programs:

a. Qualified Medicare Beneficiaries (QMB);

i. including individuals who are classified as QMB Plus and receive full Medicaid coverage in addition to QMB benefits;

b. Specified Low-Income Beneficiaries (SLMB);

i. including individuals who are classified as SLMB Plus and receive full Medicaid coverage in addition to SLMB benefits;

c. Qualified Disabled and Working Individuals (QDWI); or

d. Qualified Individuals (QI).

La. Admin. Code tit. 50, § I-8103

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:801 (April 2004), amended by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 35:1891 (September 2009), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 37:339 (January 2011).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.