§ 994.1 Medicaid recovery-Oklahoma Health Care Authority recovery-Calculations
§ 994.1. Medicaid recovery--Oklahoma Health Care Authority recovery--Calculations
A. Recovery against the party that received payment.
1. General rule. Medicaid reduces its recovery to take account of the cost of procuring the judgment or settlement, as provided in this section, if:
a. procurement costs are incurred because the claim is disputed, and
b. those costs are borne by the party against which the Oklahoma Health Care Authority seeks to recover.
2. Special rule. If the Oklahoma Health Care Authority must file suit because the party that received payment opposes the Authority's recovery, the recovery amount is as set forth in subsection E of this section.
B. Recovery against the third-party payer. If the Oklahoma Health Care Authority seeks recovery from the third-party payer, the recovery amount will be no greater than the amount determined under subsection C, D or E of this section.
C. Medicaid payments are less than the judgment or settlement amount. If Medicaid payments are less than the judgment or settlement amount, the recovery is computed as follows:
1. Determine the ratio of the procurement costs to the total judgment or settlement payment;
2. Apply the ratio to the Medicaid payment. The product is the Medicaid share of procurement costs;
3. Subtract the Medicaid share of procurement costs from the Medicaid payments. The remainder is the Medicaid recovery amount.
D. Medicaid payments equal or exceed the judgment or settlement amount. If Medicaid payments equal or exceed the judgment or settlement amount, the recovery amount is the total judgment or settlement payment minus the total procurement costs.
E. The Oklahoma Health Care Authority incurs procurement costs because of opposition to its recovery. If the Oklahoma Health Care Authority must bring suit against the party that received payment because that party opposes the Authority's recovery, the recovery amount is the lower of the following:
1. Medicaid payment; or
2. The total judgment or settlement amount, minus the party's total procurement cost.
F. Medicaid recovery worksheet. The amount to be recovered from the beneficiary is the amount Medicaid paid, less a proportionate share of the costs of procuring the judgment or settlement. The amount to be refunded is determined as follows:
If the Medicaid payment is less than the amount of judgment or settlement:
a. determine the ratio of the Medicaid payments to the total amount of the judgment or settlement,
b. apply this ratio to the costs of procuring the judgment or settlement, including attorney fees, and
c. subtract the Medicaid share of procurement costs from Medicaid payments. The remainder is the amount of reimbursement to be refunded to the Medicaid Program.
Step 1:
$______________________ / $______________________ = ______________________
Medicaid Payment Judgment/Settlement Ratio
Carry out 6 digits
Step 2:
______________________ X $______________________ = ______________________
Ratio from Step 1 Procurement Costs Medicaid Share of
Carry out 6 digits Procurement Costs
Step 3:
$______________________ - $______________________ = ______________________
Medicaid Payment Medicaid Share of Refund to Medicare
Procurement Costs
G. If the Medicaid payments equal or exceed the amount of the judgment or settlement, subtract the total procurement costs from the judgment or settlement. The remainder is the amount of reimbursement to be refunded to the Medicaid Program. The individual will not be required to refund more than the liability insurance payment minus the procurement costs.
$______________________ - $______________________ = $______________________
Judgment/Settlement Procurement Costs Refund
H. The Oklahoma Health Care Authority is authorized to seek from the Centers for Medicare and Medicaid Services any waivers or amendments to existing waivers or to amend the state Medicaid plan in order to accomplish the purposes outlined in this section.