11124 Computing the Claim - In calculating the amount of the claim, the agency shall determine the point at which the correct information should have be reported and acted upon timely allowing for timely notice as appropriate. From that point, the correct coverage (if any) shall be determined. The corrected coverage shall then be compared against the actual coverage received to determine the difference. The difference in the coverage received versus the coverage entitled to receive is the amount of the claim.
The actual amount of the claim shall be:
1. For instances where there was no eligibility:
a. Managed Care – The amount of the capitated payment made each month,
b. Fee for Service – The amount of the paid claims;
Note: For ineligibility due to excess resources, the amount of the claim cannot exceed the amount by which countable resources exceeded the allowable resource limit. If the value of the resources vary during the months of ineligibility, the highest value obtained shall be used.
2. For Nursing Home, HCBS and PACE, the amount of the understated share of cost;
3. For Working Healthy and CHIP, the amount of the understated premium;
4. For Spenddown, the difference between the capitated payment for an unmet spenddown versus a met spenddown.