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Tuesday, March 29, 2016

Medicaid Implements New Procedures for Reimbursement of Out-of-Pocket Expenses, Following the Court’s May 18, 2015 Ruling

The District of Columbia  has issued a new transmittal informing managed care organizations, providers, and the public about changes affecting reimbursement of out-of-pocket medical expenses for Medicaid beneficiaries as a result of the District Court’s May 18, 2015, Memorandum and Order.


Prior to the Court’s May 18, 2015, Memorandum and Order, all D.C. Medicaid-eligible individuals who incurred an out-of-pocket expense for drug prescriptions, doctor visits, or hospitalizations when they were eligible for Medicaid could potentially seek and receive free legal assistance from Terris, Pravlik & Millian, LLP to submit a claim for reimbursement.  If the Medicaid recipient was unsatisfied with the District of Columbia’s decision, she could seek a fair hearing before the Office of Administrative Hearings (“OAH”) to contest it.  If the Medicaid recipient was unsatisfied with the OAH decision, she could appeal it to Judge Gladys Kessler of the U.S. District Court for the District of Columbia.  Terris, Pravlik & Millian, LLP would provide free legal assistance throughout this process.


The Court’s May 18, 2015 Memorandum and Order made several changes to these procedures.  First, only Salazar class members may now obtain free legal assistance from Terris, Pravlik & Millian, LLP, concerning claims for reimbursement.  Non-class members may obtain free legal assistance from other legal aid service agencies in the District of Columbia.  


Salazar class members who can receive free legal assistance from Terris, Pravlik & Millian, LLP, are those individuals who were eligible for Medicaid or should have been eligible for Medicaid, but were forced to incur a medical expense for any of the following reasons:

  1. There was a delay in excess of 45 days in the processing of the individual’s Medicaid application.
  2. The pharmacy, clinic, hospital, or doctor’s office stated that the recipient was not eligible when she was eligible.
  3. The District of Columbia improperly terminated, suspended, or discontinued an individual’s Medicaid eligibility at the time of renewal or recertification.
  4. In the case of a child under 21 years of age, if the child was denied any Early and Periodic Screening Diagnostic Treatment service, including medical services, dental services, medication, medical equipment, supplies, or transportation services to Medicaid appointments.
  5. In the case of newborns, who lack immediate Medicaid coverage using the Medicaid number of their mothers, but are eligible for Medicaid at the time of their birth.


Second, if an individual is not happy with the results of the fair hearing before the OAH, she must now appeal the decision to the District of Columbia Court of Appeals, rather than the U.S. District Court for the District of Columbia.


As a result of the Court’s May 18, 2015 Memorandum  Opinion and Order, individuals who previously received free legal assistance to submit claims for reimbursement , but are not Salazar class members will no longer be able to obtain free legal assistance from Terris, Pravlik & Millian LLP.  These individuals include (a) Qualified Medicare Beneficiaries, who are being billed by medical providers that only accept Medicare and not District of Columbia Medicaid, (b) beneficiaries who failed to present their Medicaid or Managed Care Organization card at the point of service, and (c) beneficiaries who inform their provider of their Medicaid eligibility but are being billed for medical expenses. 


Non-class members may obtain free legal assistance from Bread for the City Legal Clinic, (202) 265-2400, Legal Aid Society, (202) 628-1161, Legal Counsel for the Elderly, (202) 434-2120, Neighborhood Legal Services, (202) 269-5100, and University Legal Services, (202)547-4747.  

Non-class members may submit a claim for reimbursement on their own and send letters to providers to request that they stop billing them for medical expenses.   If you are a Qualified Medicare Beneficiary, click here for more information about what you can do to resolve billing issues. 

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