Title: Section 511.4 - Benefit year; service units.

511.4 Benefit year; service units. Utilization thresholds are limitations on the number of service units of a given provider service type which the MA program will pay for within a benefit year.

(a) (1) For a person who is an MA recipient on March 1, 1991, who is at least 21 but less than 65 years of age, and who is eligible for MA benefits solely as a result of being an applicant for or recipient of benefits under the home relief program, the initial benefit year will begin on such date; a new benefit year will begin on March 1st of each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months. For such a person who is not an MA recipient on March 1, 1991 but who becomes eligible for MA after March 1, 1991 and prior to September 15, 1991, the initial benefit year will begin on the date such eligibility begins; a new benefit year will begin on the same day and month in each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months.

(2) For a person who is an MA recipient on September 15, 1991 and who is not subject to utilization thresholds pursuant to paragraph (1) of this subdivision, the initial benefit year will begin on such date; a new benefit year will begin on September 1st of each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months. For a person who is not an MA recipient on September 15, 1991 but who subsequently becomes eligible for MA, the initial benefit year will begin on the date such eligibility begins; a new benefit year will begin on the same day and month in each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months.

(b) A service unit is one service encounter, procedure, or formulary code, depending upon the provider service type. Service units are described more fully in sections 511.10 through 511.13 of this Part. One service unit for a specific provider service type will be recorded when the provider of care verifies recipient eligibility and obtains an authorization to provide care. If the department does not pay a claim for an authorized service unit within 180 days of the authorization, the recipient will receive one service unit credit.

 

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VOLUME C (Title 18)

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