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Georgia Medicaid Recovery

a service of HMS

Georgia Medicaid Recovery

The Department of Community Health (DCH) oversees the administration of Georgia’s Medicaid and PeachCare for Kids® programs. HMS is contracted with DCH to operate the Subrogation Unit, Estate Recovery Unit, and Trust Unit.

Subrogation Unit

The Subrogation Unit is responsible for enforcing DCH’s rights to recovery in subrogation claims, and for ensuring that the State receives its reimbursement. The Subrogation Unit’s purpose is to recover the cost of medical expenditures from liable third parties when members are involved in a personal injury action. These suits may be related to an auto accident, medical malpractice claim, general liability, worker’s compensation, mass torts, or any other tort claim where a settlement has been reached or a judgment has been awarded.

To notify DCH of an action, please print and complete the transmittal form and fax it or your standard letter of representation to our office at 855-467-3970. The Subrogation Unit will contact you with the subrogation amount to help you settle your claim. If you require a breakdown of the bills paid by DCH, please include a signed medical authorization. A link to the medical authorization form can be found under the forms menu.

Please note that the Department of Community Health has three rights to recovery:

  • Subrogation (Claims against liable third parties)
  • Assignment (Medicaid Members assign their rights to tort settlements to DCH as a condition of eligibility)
  • Department Lien (State and federal law allows DCH to place a lien in the amount of Medicaid expenditures for injuries to Members for which third parties are liable)

Estate Recovery Unit

Estate Recovery is a program required by the federal government in every state, in which the estate assets of deceased Medicaid members are used to reimburse the taxpayers for long-term care provided through Medicaid. Funds are recovered from the member’s estate after his/her death for the cost of these services. The total value of the estate must be over $25,000 for estate recovery to apply. An estate includes all real and personal property (homes, land, vehicles, cash, bank accounts) held individually or jointly. All assets of a deceased Medicaid member are subject to recovery, including property held with a life estate interest.

Trust Unit – Special Needs Trust

A Special Needs Trust (SNT) is a trust set up to provide for the extra or supplementary needs of a disabled person, beyond the basic assistance provided by government programs. SNTs are also known as Luxury, Discretionary, or Supplementary Trusts. SNTs that hold the beneficiary’s own funds are sometimes called “payback trusts” because when the SNT terminates, Medicaid must be paid back for all medical assistance received by the beneficiary during their lifetime.

Official Georgia Code Annotated and Code of Federal Regulations

The authority and subrogation recovery rights can be referenced in the following state and federal cites:

Welcome to the Subrogation, Estate Recovery, and Special Needs Trust website for the Georgia Medicaid Program, operated by HMS.

Forms

This Transmittal Form can be used to notify the Department of Community Health that your office represents a Medicaid Member who has an injury claim. It will begin the process of verifying whether Medicaid has a claim, the amount of the Medicaid claim, and the resolution of the claim. Simply complete the form and fax it to the Subrogation Unit at the fax number below. If you prefer, you can fax a letter of representation on your firm letterhead.

Attn: Subrogation Unit

Fax: 855-467-3970

Click here for the Transmittal Form

Medical Authorization Form

If you would like the Department of Community Health to provide your attorney, legal representative, or claim adjuster with a list of the providers paid for services related to your accident or injury, please print the following form, sign, date, and fax it to:

Medical Authorization Form

Attn. Subrogation Unit.
Fax: 855-467-3970

Click here for the Medical Authorization Form

Other Resources

Transmittal Form

– See more at: http://hms.com/ga/medicaidrecovery/forms/#sthash.EwB7ZCKw.dpuf

Subrogation FAQ

1. What do you do if your client is involved in an accident?

Ask your client if they are covered under Medicaid or PeachCare for Kids. You may also contact our office to verify that your client is covered under these programs. You should also check with your client to see if they are covered under Managed Care. If so, you will need to contact the appropriate Managed Care provider for its lien amount.

2. What are the attorney’s responsibilities?

Official Code of Georgia §9-2-21 requires the attorney or legal representative to notify the Department of Community Health prior to initiating a tort recovery action. Notification is easy; a simple phone call to 678-564-1163 takes care of it. You may also notify the Subrogation Unit in writing of your representation via U.S. mail, fax (855-467-3970), or this website.

Please remember that the Medicaid application is a binding legal document. When a member signs this application, he or she acknowledges that medical benefits paid on his or her behalf must be reimbursed to the Department if he or she is entitled to benefits from a third party.

3. What will the Subrogation Unit do for you and your client?

Upon contact by an attorney’s office, the Subrogation Unit will verify the member’s eligibility status at the time of the accident or injury, determine whether DCH incurred any medical expenses as a result of the accident or injury, and generate a complete medical history of injury-related claims. This information is available to attorneys who submit a written request along with a signed medical authorization from the client granting the attorney access to the member’s medical records.

4. What medical assistance costs are recovered?

The Subrogation Unit will request reimbursement for injury-related charges only. A reimbursable injury/loss may be related to an auto accident, medical malpractice, general liability, worker’s compensation, or any other tort claim where a settlement has been reached or a judgment has been awarded.

In most cases, Medicaid pays less than the amount of charges billed by the Medicaid provider. What happens to the difference? Contractually, the provider must accept Medicaid’s payment as payment in full and cannot bill the customer for the difference. In seeking reimbursement, Medicaid can only legally claim repayments up to the amount that it has expended. This is another good reason to contact the Subrogation Unit. Once a provider has submitted claims for adjudication, the provider must accept Medicaid’s payment. By requesting a detailed list of the claims paid by Medicaid, you can ensure that your client is not paying a claim twice or at a higher rate. By law Medicaid is the payer of last resort. Where private insurance exists, any and all other monies should be utilized before Medicaid provides any assistance.

5. What happens if the member fails to pay the Department’s claim?

Failing to reimburse DCH may impact the member’s present and future Medicaid eligibility, and will result in an outstanding lien on behalf of Medicaid or PeachCare for Kids.

6. How do you repay the Department of Community Health?

Make your check payable to the Georgia Department of Community Health and mail it to DCH at:
Georgia Department of Community Health
P.O. BOX 1984
Atlanta GA 30301-1984

Download our Casualty brochure here.

– See more at: http://hms.com/ga/medicaidrecovery/subrogation/#sthash.BEWZhvoD.dpuf

Estate Recovery FAQ

1. Why does Georgia have an Estate Recovery program?

The Medicaid program is a joint federal/state program. Federal law requires states to develop and enforce an Estate Recovery Program. DCH has the responsibility to recover money paid on behalf of the Medicaid member up to the full amount that Medicaid paid. This requirement is set forth in Title XIX of the Social Security Act.

To comply with this federal requirement Georgia adopted Chapter 111-3-8 of the Rules of the Department of Community Health for Medical Assistance. These Rules govern the Georgia Estate Recovery Program.

2. Who is affected by Estate Recovery?

The Estate Recovery Program applies to a person who receives any of the following Medicaid services:

  • A person of any age living in a nursing home, intermediate care facility for the mentally retarded, or other mental health institution
  • A person of any age living in a long-term care program outside their own family’s home
  • A person 55 years of age or older who has a worker coming to their home to help them with healthcare needs. For example, a nurse who comes to the member’s home to help with medications or to change bandages, or a worker who comes to the member’s home to help with Activities of Daily Living (bathing, dressing, transferring, toileting, eating).

3. What Medicaid expenses must be reimbursed?

Recoverable Medicaid expenses include the following:

  • Nursing facility services
  • Personal care services
  • Home and community-based services
  • Hospital services
  • Prescription drug services

4. Can Estate Recovery be delayed or deferred?

Federal law provides certain specific instances in which the application of Estate Recovery may be delayed or deferred, including:

  • Medicaid member must have passed away and the surviving husband/wife must have also passed away. Until both have passed, recovery will be delayed.
  • Medicaid member must not have dependent children younger than 21 years of age. Until the child reaches age 21, recovery will be delayed.
  • Medicaid member must not have any dependent children of any age with a disability or blindness that has been confirmed by a government agency. Recovery will be delayed until the disabled/blind child has also passed.
  • Medicaid member is survived by a sibling with an equity interest in the home and who was residing in the home continuously for at least one year prior to the member entering an institution, and continues to reside in the home.
  • There is a son or daughter of the individual residing in the home, who has resided there for at least two years immediately before the date of the individual’s admission to the institution, has resided there on a continuous basis since that time, and can establish to the Department’s satisfaction that he/she has been providing care which permitted the individual to reside at home rather than in an institution.

5. What is an undue hardship?

DCH will waive recovery if an undue hardship exists. One of two conditions must exist for an undue hardship waiver to be granted by DCH:

  • The asset to be recovered is an income-producing farm of one or more of the heirs, and the annual gross income is limited to $25,000 or less, and is the sole income of one or more heirs;
  • Recovery of assets would result in the applicant becoming eligible for needs-based governmental assistance.

A request for an undue hardship waiver may be made within 30 days of receiving notice of Medicaid’s claim against the estate.

6. How does Medicaid pursue estate recovery?

The Estate Recovery process begins with the issuance of a Notice of Intent to File Estate Recovery Claim. This Notice is mailed to the personal representative of the estate to advise them of the claim. The personal representative should then contact the Estate Recovery Unit to receive detailed information about the recovery process.

7. What is a lien?

“Lien” means a claim, encumbrance, or charge against the Medicaid member’s real or personal property on account of medical assistance correctly paid for the member. A lien may be placed on the real property of a member who is an inpatient of a nursing facility, intermediate care facility for the mentally retarded, or other institution; or a lien may be placed on both real and personal property after the member’s death.

8. How should notification be given of a Medicaid member’s death?

Within 30 days of the member’s death, the provider, attorney, personal representative, or case manager (if applicable) should contact the Estate Recovery Unit by fax, phone, or mail (see contact information below). The initial notification should include:

  • Full name of the deceased member
  • Medicaid ID number and/or Social Security number
  • Date of death and copy of death certificate
  • Name, address, and telephone number of the personal representative and/or attorney handling the estate
  • Information on any estate proceedings that may have been filed in the Probate Court

Georgia Department of Community Health Estate Recovery Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339
Phone: 770-916-0328
Fax: 678-569-0066

Once the notification of death has been received, the Estate Recovery Unit will advise the personal representative and/or attorney on how to proceed.

– See more at: http://hms.com/ga/medicaidrecovery/estate-recovery/#sthash.xSmteqG1.dpuf

Trust Unit/Special Needs Trusts FAQ

1. What is a trust?

A trust is a legal arrangement where property is held by a trustee (the person who handles the trust) for the benefit of a beneficiary (the person for whom the trust is created). It is usually established either by a written trust agreement or by the terms of a will. The general administration of the trust is governed by the terms of the document that creates it.

2. What is the Trust Unit?

The Trust Unit is the office that reviews Special Needs Trusts (SNTs) and annual trust accountings sent to the Legal Services Section of the Georgia DCH.

3. Why does Georgia review Special Needs Trusts?

If a SNT does not meet certain legal requirements the beneficiary might not be able to become eligible for Medicaid or might lose eligibility for Medicaid. These legal requirements are specified by federal law and policy and Georgia law and policy.

4. What rules apply to trust expenditures?

In general terms, trustees must always follow the federal and state law applicable to Special Needs Trusts, and also Georgia Medicaid policy. This Georgia policy is located in the Georgia Department of Human Resources’ Division of Family and Children Services (DFCS) Medicaid Manual at Section 2337 for Qualified Income Trusts and Pooled Trusts and at Section 2346 for Special Needs Trusts. The Manual can be found in local DFCS offices.

5. What happens at the trust beneficiary’s death?

Notice of the death must be given to the Trust Review Unit and DCH Third Party Liability within five (5) days of the death, preferably by fax (678-564-1169). The notification should include:

  • Full name of the deceased beneficiary
  • Medicaid ID number and/or Social Security number of the beneficiary
  • Date of death and copy of the death certificate
  • Contact information for the personal representative and/or attorney handling the estate, including name, address, and telephone number

When the Death Certificate is issued, arrangements for appropriate repayment of medical assistance received will be made and payment, along with a copy of the Death Certificate, must be sent to:
Georgia Department of Community Health
Attn: Trust Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339

6. What trusts need to be sent in for review?

Trusts that need to be sent to the DCH Trust Unit for review include (1) Special Needs Trusts funded with assets of the person establishing the trust or with assets of the beneficiary, (2) Pooled Trust Accounts (3) Testamentary Special Needs Trusts (including those set up in a Living Trust or Family Trust), and (4) Third Party Special Needs Trusts where the beneficiary is receiving Medicaid.

7. Where are trusts sent for review?

Trust documents and supporting documentation are sent to:
Georgia Department of Community Health
Attn: Trust Review Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339

Phone: 678-564-1168
Fax: 678-564-1169

8. What is the review process?

The review process is a standardized system in which the trust document and all supporting documentation are reviewed to make sure that the requirements of federal law and policy and Georgia law and policy have been met. The source of funds going into the trust must be revealed. If the funds come from a lawsuit or settlement and there is a pre-trust Medicaid lien, the lien must be resolved before the trust can be approved. Opportunities are provided to make needed corrections or provide additional information. The process is designed to encourage approvals.

9. How long does the review take?

If the trust document and all necessary supporting documentation are submitted and the required criteria are met, a trust generally can be approved in 30 to 45 days. If there are problems or deficiencies, there is a More Information Needed process that provides notice of the specific problems and/or deficiencies and allows time to correct them.

10. What happens if the trust is approved?

If the trust is approved, the approval is entered in the records and a formal Approval Notice is issued and mailed to the person who submitted the trust. The notice includes a reminder that an annual inventory update and accounting must be filed within sixty (60) days of the anniversary date of the trust.

12. Who reviews trust accountings?

Annual inventory updates and accountings are reviewed by the Accounting Review staff of the Trust Unit, which includes a Certified Public Accountant (CPA).

13. What are the trust accounting requirements?

The basic requirement is that the trustee must annually file an inventory update and accounting with the Trust Unit. The inventory update and accounting must be filed within sixty (60) days of the anniversary date of the establishment of the trust, and must include copies of financial statements that verify the trust inventory. A general guide on how to prepare accountings is available from the Trust Unit.

14. What is the accounting review process?

The accounting review process consists of a financial examination of the trust inventory updates and annual accountings filed by the trustees of approved SNTs. The general purpose of this review is to verify the financial integrity of the trust and that the trust is being administered for the sole benefit of the beneficiary. At the conclusion of the trust accounting review process, the annual inventory update and accounting is formally approved or denied. Denial may result in the loss of eligibility for Medicaid.

Contact Information

SUBROGATION UNIT
Georgia Department of Community Health
Subrogation Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339

Phone: 678-564-1163
Fax: 855-467-3970

ESTATE RECOVERY UNIT
Georgia Department of Community Health
Estate Recovery Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339

Phone: 770-916-0328
Fax: 678-569-0066

TRUST UNIT/SPECIAL NEEDS TRUSTS
Georgia Department of Community Health
Trust Review Unit
900 Circle 75 Parkway
Suite 650
Atlanta, GA 30339

Phone: 678-564-1168
Fax: 678-564-1169

– See more at: http://hms.com/ga/medicaidrecovery/contact-information/#sthash.CwKQOvGh.dpuf