N.H. Admin. Code § He-W 521.02

Current through Register No. 50, December 12, 2024

Section He-W 521.02 - Applicant, Recipient, and Recipient's Responsible Party Responsibilities

(a) A medicaid recipient or recipient's responsible party shall:

(1) Inform the provider of the recipient's medicaid coverage and third party insurance coverage, if applicable, prior to receiving services;

(2) Present the recipient's medicaid identification (ID) card and third party insurance card, if applicable, to the service provider at the time of service;

(3) Comply with all requirements of the recipient's private insurance for payment of any item, supply, or service, if the recipient is covered under another third party insurance or Medicare;

(4) Inform the department of any other medical insurance coverage or changes to insurance coverage; and

(5) Report any changes in circumstance to the department that may affect the recipient's eligibility or access to care, such as a change of name, address, or income, within 10 days of the change taking effect.

(b) The recipient or recipient's responsible party shall be responsible for payment of an item, supply, or service if:

(1) The recipient was not eligible for medicaid on the date of service(s);

(2) The recipient selects an item, supply, or service that is not covered under the medicaid program and the provider has informed the recipient prior to service that the item, supply, or service shall not be covered by medicaid;

(3) It is an ancillary services not associated with a covered service paid by medicaid;

(4) The recipient receives an item, supply, or service from an individual or entity that is not an enrolled medicaid provider, unless the managed care organization (MCO) approves the provider as an out-of-network provider and approves the service for payment or it was an emergency service in which the recipient was unable to go to an in-network provider with medicaid, such as an out-of-state accident;

(5) A provider enrolled in medicaid informs the recipient in writing that the provider shall not accept the recipient as a medicaid patient, but the recipient still requests the item, supply, or service from the provider;

(6) The recipient is enrolled with a third party insurance and the recipient's failure to comply with all requirements of that insurance carrier, as required by (a)(3) above, results in the third party coverage being denied; or

(7) The recipient otherwise requests that the item, supply, or service not be processed through medicaid.

(c) The applicant, recipient, or recipient's responsible party shall:

(1) Notify the department or MCO of any third party insurance coverage, or any accidental or work related injury:

a. At the time of application for medical assistance;

b. At the time of redetermination of medical assistance eligibility;

c. Within 10 business days of the start of insurance coverage;

d. Within 10 business days of the accident or injury date; or

e. Within 10 business days of the effective date of any changes in insurance coverage;

(2) Supply the department or MCO with the following information regarding third party insurance:

a. Name of medicaid recipient covered by insurance policy;

b. Name of the insurance company;

c. Insurance policy number;

d. Insurance group number, if applicable;

e. Date the insurance became active;

f. Type of insurance coverage;

g. Subscriber's name of the insurance; and

h. Copies, front and back, of the insurance cards, if requested; and

(3) Notify the department of coverage, or a change in coverage, by contacting the department or MCO.

N.H. Admin. Code § He-W 521.02

Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).