Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 09-16 September 15, 2009 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Recovery of Overpayment of Member Benefits Program Introduction When MassHealth members or their authorized representatives provide incorrect or misleading information or fail to report any change in status, there is a possibility that members will receive benefits for which they are not eligible. The MassHealth Operations Integrity Unit, in conjunction with the Bureau of Special Investigations, manages the Recovery of Overpayment of Member Benefits Program to recover benefits paid to ineligible members. This memo explains the program’s purpose, how the Operations Integrity Unit initiates and manages the process, and what MassHealth Enrollment Center (MEC) staff need to do if they receive calls about this program. Program Purpose The purpose of the Recovery of Overpayment of Member Benefits Program is to recover money MassHealth has paid for benefits when the member was ineligible. Members are required to repay any direct claim or capitation payments made on their behalf during the period of ineligibility. Operations Integrity Unit Role The Bureau of Special Investigations refers certain completed investigated fraud cases to the Operations Integrity Unit for recovery of benefit payments through an administrative collection process. The Operations Integrity Unit issues a notice to the member outlining the violation and a request for repayment of the total claims and capitation paid by MassHealth. This notice includes appeals rights. (continued on next page) Operations Integrity Unit Role (cont.) Additionally, the Operations Integrity Unit manages the program by making payment arrangements when needed and sending supplemental notices when payments are 30, 60, 90, and 120 days in arrears. All notices include the Operations Integrity Unit address and telephone number. MEC Role If an individual calls a MEC about a notice for repayment of benefits, the call should be referred to the Operations Integrity Unit at 1-877-437-2830. No other action is required. Appeals A staff member from the Operations Integrity Unit and, when required, a representative from the Bureau of Special Investigations will be present at appeal hearings. The Operations Integrity Unit will be responsible for any eligibility issues that may arise. Attachments The following attachments are included with this memo: * Attachment 1: Recovery of Overpayment of Member Benefits (RMB- RO (08/09)); * Attachment 2: Regulations (RMB-Reg (08/09)); * Attachment 3: Recovery of Overpayment of Member Benefits — Payment Plan Agreement (RMB-PPA (08/09)); * Attachment 4: Recovery of Overpayment of Member Benefits — 30-Day Late Notice (RMB-30 (08/09)); * Attachment 5: Recovery of Overpayment of Member Benefits — 60-Day Late Notice (RMB-60 (08/09)); * Attachment 6: Recovery of Overpayment of Member Benefits — 90-Day Late Notice (RMB-90 (08/09)); and * Attachment 7: Recovery of Overpayment of Member Benefits — 120-Day Late Notice (RMB-120 (08/09)). Questions If you have any questions about this memo, please have your MEC designee call the Policy Hotline. EOM 09-16 September 15, 2009 Attachment 1 Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits
Dear , As explained in more detail below, MassHealth has determined that from to you or other members of your household got benefits to which you were not entitled. You owe $<$,$$$.$$> for those benefits. MassHealth has the right to recover payment for benefits that a member was not eligible for when he or she got the benefit. MassHealth has this right no matter who was responsible or if there was fraudulent intent. See MassHealth regulations at 130 CMR 501.012 and 515.010. An applicant or member must tell MassHealth within 10 days or as soon as possible about changes that may affect eligibility. See 130 CMR 501.010 and 515.008. You have signed a Medical Benefits Request (MBR) or an Eligibility Review Form (ERV). On this form, you told us that the information was correct. You said that you would tell MassHealth within 10 days or as soon as possible of a change that might affect eligibility. MassHealth has reviewed your case and found that you did not to report . Since , you or other members of your household were no longer eligible for any MassHealth benefits from to . An investigation was done by the Bureau of Special Investigations pursuant to Massachusetts General Law, chapter 11, section 17. Based on this review, we have determined that you or other members of your household got MassHealth benefits to which you were not entitled. You owe $<$,$$$.$$> for those benefits. Please send a bank check or money order for the amount of $<$,$$$.$$> within 14 days from the date of this letter. Make this check or money order payable to the “Commonwealth of Massachusetts.” Send it in the enclosed self-addressed envelope. If you need to work out a payment plan, please call the number at the top of this notice. If you owe any money and do not pay, MassHealth may collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. We may use any or all of these methods to get the overpayment. Your Right to Appeal: If you think that we are wrong, you may appeal our decision within 30 calendar days from the date you got this written notice. Please see the Request for a Fair Hearing form enclosed with this notice. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-RO (08/09) EOM 09-16 September 15, 2009 Attachment 2 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Regulations MassHealth regulations 501.009: Rights of Applicants and Members The policies of the MassHealth Program are administered in accordance with federal and state law. Applicants and members must be informed of their rights and responsibilities with respect to the MassHealth Program. (A) Right to Nondiscrimination and Equal Treatment. The Massachusetts Division of Medical Assistance does not discriminate on the basis of race, color, sex, sexual orientation, religion, national origin, disability, or age in admission or access to, or treatment or employment in, its programs or activities. Grievance procedures for resolution of discrimination complaints are administered and applied by the Division's Affirmative Action Office. (B) Right to Confidentiality. The confidentiality of information obtained by the Division during the MassHealth eligibility process is protected in accordance with federal and state regulations. The use and disclosure of information concerning applicants, members, and legally liable third parties is restricted to purposes directly connected with the administration of MassHealth as governed by state and federal law. (C) Right to Timely Provision of Benefits. Eligible applicants and members have the right to the timely provision of benefits as defined in 130 CMR 502.000. (D) Right to Information. Persons who inquire about MassHealth, either orally or through a written request, have the right to receive information about medical benefits, coverage type requirements, and their rights and responsibilities as applicants and members of MassHealth. (E) Right to Apply. Any person, individually or through an eligibility representative, has the right, and must be afforded the opportunity without delay, to apply for MassHealth. (F) Right to be Assisted by Others. (1) The applicant or member has the right to be accompanied and represented by an eligibility representative during the eligibility process, and by an appeal representative during the appeal process. The Division must provide copies of all eligibility notices to an applicant’s or member’s eligibility representative, and must provide copies of all documents related to the fair hearing process to an applicant’s or member’s appeal representative. (2) An application for MassHealth may be filed by an eligibility representative on behalf of a deceased person. (3) An appeal on behalf of a deceased person may be filed by an appeal representative, as defined in 130 CMR 501.001. RMB-Reg (08/09) (G) Right to Inspect the MassHealth Case File. The applicant or member has the right to inspect information in his or her MassHealth case file and contest the accuracy of the information. (H) Right to Appeal. The applicant or member has the right to appeal and request a fair hearing as the result of any adverse action or inaction taken by the Division. The request will not be granted if the sole issue is a federal or state law requiring an automatic change adversely affecting members. (I) Right to Interpreter Services. The Division will inform applicants and members of the availability of interpreter services. Unless the applicant or member chooses to provide his or her own interpreter services, the Division will provide either telephonic or other interpreter services whenever: (1) the applicant or member who is seeking assistance from the Division has limited English proficiency or sensory impairment and requests interpreter services; or (2) the Division determines such services are necessary. (J) Right to a Certificate of Creditable Coverage Upon Termination of MassHealth. The Division will provide a Certificate of Creditable Coverage to members whose coverage under MassHealth Standard or CommonHealth, or a MassHealth health plan under Family Assistance, Basic, or Essential has ended. The Division will issue a Certificate to members within one week of their MassHealth termination, or within one week of the request for a Certificate, as long as the request is made within 24 months of their MassHealth termination. The Certificate may allow members to waive or reduce the length of preexisting- condition waiting periods when they enroll in a new health plan offered by other insurance. If a member’s MassHealth termination also terminates the coverage of his or her dependents, the dependents will be included on the Certificate. 501.010: Responsibilities of Applicants and Members (A) Responsibility to Cooperate. The applicant or member must cooperate with MassHealth in providing information necessary to establish and maintain eligibility, and must comply with all the rules and regulations of MassHealth, including recovery and obtaining or maintaining available health insurance. (B) Responsibility to Report Changes. The applicant or member must report to MassHealth, within 10 days or as soon as possible, changes that may affect eligibility. Such changes include, but are not limited to, income, the availability of health insurance, and third-party liability. (C) Cooperation with Quality Control. The Quality Control Division will periodically conduct an independent review of eligibility factors in a sampling of case files. When a case file is selected for review, the member must cooperate with the representative of Quality Control. Cooperation includes, but is not limited to, a personal interview and the furnishing of requested information. If the member does not cooperate, MassHealth benefits may be terminated for the family group. 501.011: Referrals to Investigative Units Intentional false statements or fraudulent acts made in connection with obtaining medical benefits or payments under MassHealth are punishable under M.G.L. c. 118E, § 39 by fines, imprisonment, or both. In all cases of suspected fraud, MassHealth staff will make a referral to the Bureau of Special Investigations, or other appropriate agencies. 501.012: Recovery of Overpayment of Medical Benefits MassHealth has the right to recover payment for medical benefits to which the member was not entitled, regardless of who was responsible and whether or not there was fraudulent intent. No provision under 130 CMR 501.012 will limit MassHealth’s right to recover overpayments. 515.007: Rights of Applicants and Members The policies of MassHealth are administered in accordance with federal and state law. Applicants and members must be informed of their rights and responsibilities with respect to MassHealth. (A) Right to Nondiscrimination and Equal Treatment. The Division of Medical Assistance does not discriminate on the basis of race, color, sex, sexual orientation, religion, national origin, disability, or age in admission or access to, or treatment or employment in, its programs or activities. Grievance procedures for resolution of discrimination complaints are administered and applied by the Division’s Affirmative Action Office. (B) Right to Confidentiality. The confidentiality of information obtained by the Division during the MassHealth eligibility process is protected in accordance with federal and state regulations. The use and disclosure of information concerning applicants, members, and legally liable third parties is restricted to purposes directly connected to the administration of MassHealth as governed by state and federal law. (C) Right to Timely Provision of Benefits. Eligible applicants and members have the right to the timely provision of benefits, as defined in 130 CMR 516.000. (D) Right to Information. Persons who inquire about MassHealth, either orally or through a written request, have the right to receive information about medical benefits, coverage type requirements, and their rights and responsibilities as applicants and members of MassHealth. (E) Right to Apply. Any person, individually or through an eligibility representative, has the right, and must be afforded the opportunity without delay, to apply for MassHealth. (F) Right to be Assisted by Others. (1) The applicant or member has the right to be accompanied and represented by an eligibility representative during the eligibility process, and by an appeal representative during the appeal process. The Division must provide copies of all eligibility notices to an applicant’s or member’s eligibility representative, and must provide copies of all documents related to the fair hearing process to an applicant’s or member’s appeal representative. (2) An application for MassHealth may be filed by an eligibility representative on behalf of a deceased person. (3) An appeal on behalf of a deceased person may be filed by an appeal representative, as defined in 130 CMR 515.001. (G) Right to Inspect the MassHealth Case File. The applicant or member has the right to inspect information in his or her MassHealth case file and contest the accuracy of the information. (H) Right to Appeal. The applicant or member has the right to appeal and request a fair hearing as the result of any adverse action or inaction taken by MassHealth. The request will not be granted if the sole issue is a federal or state law requiring an automatic change adversely affecting members. (I) Right to Interpreter Services. MassHealth will inform applicants and members of the availability of interpreter services. Unless the applicant or member chooses to provide his or her own interpreter services, MassHealth will provide either telephonic or other interpreter services whenever: (1) the applicant or member who is seeking assistance from MassHealth has limited English proficiency or sensory impairment and requests interpreter services; or (2) MassHealth determines such services are necessary. (J) Right to a Certificate of Creditable Coverage. Upon termination of MassHealth, MassHealth provides a Certificate of Creditable Coverage to members whose coverage under MassHealth Standard, CommonHealth, Essential, or Basic has ended. MassHealth issues a Certificate to members within one week of their MassHealth termination, or within one week of the request for a Certificate, as long as the request is made within 24 months of their MassHealth termination. The Certificate may allow members to waive or reduce the length of preexisting- condition waiting periods when they enroll in a new health plan offered by private insurance. If a member’s MassHealth termination also terminates the coverage of his or her dependents, the dependents are included on the Certificate. 515.008: Responsibilities of Applicants and Members (A) Responsibility to Cooperate. The applicant or member must cooperate with MassHealth in providing information necessary to establish and maintain eligibility, and must comply with all the rules and regulations of MassHealth, including recovery. (B) Responsibility to Report Changes. The applicant or member must report to MassHealth, within 10 days or as soon as possible, changes that may affect eligibility. Such changes include, but are not limited to, income, assets, inheritances, gifts, transfers of and proceeds from the sale of real or personal property, distributions from or transfers into trusts, address, the availability of health insurance, immigration status, and third-party liability. (C) Cooperation with Quality Control. The Quality Control Division periodically conducts an independent review of eligibility factors in a sampling of case files. When a case file is selected for review, the member must cooperate with the representative of Quality Control. Cooperation includes, but is not limited to, a personal interview and the furnishing of requested information. If the member does not cooperate, MassHealth benefits may be terminated. 515.009: Referrals to Investigative Units Intentional false statements or fraudulent acts made in connection with obtaining medical benefits or payments under MassHealth are punishable under M.G.L. c. 118E § 39 by fines, imprisonment, or both. In all cases of suspected fraud, Division staff will make a referral to the Bureau of Special Investigations, or other appropriate agencies. 515.010: Recovery of Overpayment of Benefits The Division has the right to recover payment of benefits to which the member was not entitled at the time the benefit was received, regardless of who was responsible and whether or not there was fraudulent intent. No provision under 130 CMR 515.011 will limit the Division’s right to recover overpayments. Office of the Comptroller Regulations Regulations for the Massachusetts Office of the Comptroller can be found at www.mass.gov/osc. EOM 09-16 September 15, 2009 Attachment 3 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits Payment Plan Agreement
Dear , Beginning and every month after that until you have paid the full amount that you owe, you have agreed to make payments of $<$$.$$> per month on your balance of $<$,$$$.$$>. Your payment must be made by the of each month or MassHealth may take further action to collect the full balance owed. According to the Massachusetts Office of the Comptroller regulations at 815 CMR 9.00, MassHealth can collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. If MassHealth does sue, we may try to get back not only the amount you owe but also attorney’s fees and costs. MassHealth may choose to use any or all of these methods to recover an overpayment. If your payment is going to be late or you are having problems paying the agreed-to amount, please call 1-877-437-2830 immediately. Please make your check or money order payable to the “Commonwealth of Massachusetts.” Place it in the enclosed self-addressed envelope. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-PPA (08/09) EOM 09-16 September 15, 2009 Attachment 4 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits 30-Day Late Notice
Dear , We have not received your payment of $<$,$$$.$$> that was due on . Please make your payment today. If you cannot make your payment, please call 1-877-437- 2830 right away. We can help you start a payment plan. If you have already made your payment, thank you. Important: If you do not send in your payment or make other arrangements, MassHealth may take further action to collect the full balance owed. According to the Massachusetts Office of the Comptroller regulations at 815 CMR 9.00, MassHealth can collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. If MassHealth does sue, we may try to get back not only the amount you owe but also attorney’s fees and costs. MassHealth may choose to use any or all of these methods to recover an overpayment. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-30 (08/09) EOM 09-16 September 15, 2009 Attachment 5 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits 60-Day Late Notice
Dear , We have not received your payment of $<$,$$$.$$> that was due on . Please make your payment today. If you cannot make your payment, please call 1-877-437- 2830 right away. We can help you start a payment plan. If you have already made your payment, thank you. Important: If you do not send in your payment or make other arrangements, MassHealth may take further action to collect the full balance owed. According to the Massachusetts Office of the Comptroller regulations at 815 CMR 9.00, MassHealth can collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. If MassHealth does sue, we may try to get back not only the amount you owe but also attorney’s fees and costs. MassHealth may choose to use any or all of these methods to recover an overpayment. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-60 (08/09) EOM 09-16 September 15, 2009 Attachment 6 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits 90-Day Late Notice
Dear , We have not received your payment of $<$,$$$.$$> that was due on . Please make your payment today. If you cannot make your payment, please call 1-877-437- 2830 right away. We can help you start a payment plan. If you have already made your payment, thank you. Important: If you do not send in your payment or make other arrangements, MassHealth may take further action to collect the full balance owed. According to the Massachusetts Office of the Comptroller regulations at 815 CMR 9.00, MassHealth can collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. If MassHealth does sue, we may try to get back not only the amount you owe but also attorney’s fees and costs. MassHealth may choose to use any or all of these methods to recover an overpayment. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-90 (08/09) EOM 09-16 September 15, 2009 Attachment 7 Commonwealth of Massachusetts MassHealth Operations Integrity Unit Executive Office of Health and Human Services 600 Washington Street www.mass.gov/masshealth Boston, MA 02111 Operations Integrity Unit 1-877-437-2830 Recovery of Overpayment of Member Benefits 120-Day Late Notice
Dear , We have not received your payment of $<$,$$$.$$> that was due on . Please make your payment today. If you cannot make your payment, please call 1-877-437- 2830 right away. We can help you start a payment plan. If you have already made your payment, thank you. Important: If you do not send in your payment or make other arrangements, MassHealth may take further action to collect the full balance owed. According to the Massachusetts Office of the Comptroller regulations at 815 CMR 9.00, MassHealth can collect the money by taking any payments you get from the Commonwealth of Massachusetts. If the money you owe is collected by taking a payment, the Office of the Comptroller and the Department of Revenue (for an income tax refund) will charge a fee of up to $25.00. MassHealth may also send your account to a collection agency or sue you to collect the overpayment. If MassHealth does sue, we may try to get back not only the amount you owe but also attorney’s fees and costs. MassHealth may choose to use any or all of these methods to recover an overpayment. Thank you for your cooperation. MassHealth Operations Integrity Unit RMB-120 (08/09)