Current through Register Vol. 46, No. 21, November 10, 2023
Section 10 CCR 2505-10-8.063 - MEDICAL ASSISTANCE ESTATE RECOVERY.11 The state department may seek to recover medical assistance expenditures correctly paid from the estates of deceased individuals as follows: A. Recoveries of payments are made for all medical assistance paid on behalf of an individual who was institutionalized at the time he/she received medical assistanceB. Recoveries of payments are made for nursing facility services, home and community-based services, and related hospital and prescription drug services paid on behalf of an individual who was 55 years of age or older at the time he/she received medical assistance. The state department does not make the optional recoveries described under federal law in 42 U.S.C. § 1396p(b)(1)(B)(ii) in the case of an individual described in this subsection..12 The state department may limit estate recovery to recoveries that are cost-effective. The term "cost effective" means that the amount of medical assistance expenditures likely to be recovered is greater than the likely cost to the state of the recovery. .13 The state department may file a lien on the real property of an institutionalized person for the amount of medical assistance correctly paid on behalf of the person, only if: A. the department determines that the medical assistance recipient cannot reasonably be expected to be discharged from the institution and to return home; andB. there is no spouse of the recipient lawfully residing in the home; andC. there is no child of the recipient under age 21 or blind or disabled dependent of the recipient lawfully residing in the home; andD. there is no sibling of the recipient who has an equity interest in the home and who was lawfully residing in the home for at least one year immediately prior to the date the recipient was admitted to the institution; andE. later recovery from the estate is likely to be cost-effective.
Medical assistance payments made on behalf of an institutionalized recipient during the time that all lien criteria are not met will be subject to a lien at such time that all lien criteria are met..14 The state department shall determine whether a medical assistance recipient reasonably can be expected to be discharged from the institution and to return home. This determination shall be made by the Utilization Review Contractor after notice and opportunity for a hearing. The determination that the recipient is not likely to return home will be used to decide if a lien will be filed. This determination will not change an exempt home into a countable resource for eligibility purposes.
The notice to the recipient shall include the following:A. A statement of the action that the Utilization Review Contractor intends to take, the reasons for the intended action, and the specific regulations that support the action.B. An explanation of the term "lien", and that imposing a lien does not mean that the individual will lose ownership of the home.C. A statement that the determination will not result in a loss of eligibility for medical assistance benefits.D. The process by which a recipient may request a hearing to appeal the decision of the Utilization Review Contractor.
The decision may be appealed through the procedures in the RECIPIENT APPEALS PROTOCOLS/PROCESS Section of this staff manual.
The state department shall dissolve any lien on a recipient's home if the recipient is discharged from the institution and returns to the home subject to the lien..15 The state department shall not recover medical assistance expenditures correctly paid from the estate of a medical assistance recipient if:A. There is a surviving spouse of the recipient; orB. There is a child of the recipient under age 21 or a blind or disabled dependent of the recipient.8.063.16 In addition to the prohibitions of 8.063.15, the state department shall not recover medical assistance expenditures correctly paid from the sale of the recipient's home, whether or not the home was subject to a lien, if:A. there is a sibling of the recipient who was lawfully residing in the home for at least one year immediately prior to the date the recipient was admitted to the institution and who has continuously lived in the home since that date; orB. there is a son or daughter of the recipient who was lawfully residing in the home for at least two years immediately prior to the date the recipient was admitted to the institution and who has continuously lived in the home since that date, and who provided care to the recipient which permitted the recipient to reside at home rather than in an institution.
If either of the two conditions above exist, the state department may recover medical assistance expenditures correctly paid from assets in the estate other than the sale of the recipient's home..17 The state department shall file liens and recover expenditures for medical assistance provided on or after July 1, 1992..18 The state department may compromise, settle, or waive recovery of medical assistance expenditures if it determines good cause to do so. The department shall determine that good cause exists if: A. it concludes that without receipt of the proceeds of the estate, the heirs would become eligible for assistance payments and/or medical assistance programs; orB. it concludes that allowing the heirs to receive the inheritance from the estate will enable these individuals to discontinue eligibility for assistance payments and/or medical assistance programs; orC. it concludes that the home is part of a business, including a working farm or ranch, and recovery of medical assistance expenditures will result in the heirs to the estate losing their means of livelihood..19 The state department may agree to a payment plan for repayment of any debt owed the state under the Medical Assistance Estate Recovery Program.