clarifying information
CONSUMER REIMBURSEMENTS
We make reimbursements to consumers who have incurred child care expenses that would have otherwise been paid by DSHS. There is not a time limit on how far back the reimbursement time period can be. However, the client must have been eligible for child care for the time period covered by the reimbursement. For payment begin dates see:
http://www.dshs.wa.gov/esa/wccc/Sections/PymtsABegin.htm.
Take the following steps to reimburse a consumer for child care
expenses:
Determine if the consumer meets all WCCC eligibility criteria for the time period covering the reimbursement period; Verify attendance of the children for the reimbursement period; Verify amounts paid to the eligible provider (the provider must normally accept subsidies) for the reimbursement period; Compute the copayment amount for each of the months in question; Determine the monthly State maximum payment rate applying the rate in effect at the time of service.
| NOTE: |
Remember, the amount the department will reimburse or pay retroactively is the State maximum or the provider's usual rate, whichever is less. |
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Compare the State maximum rate with the total
paid by the consumer and any remaining balance owed to the provider;
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Subtract any amount paid or expected to be
paid by a third party;
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Total the amount owed for all months, which equals the amount to be reimbursed to the consumer.
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Subtract the copayment amount from what the State owes the consumer for each month; and
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Inform the consumer of the copayment amount
for each month by completing and sending the DSHS 7-066 ("WCCC Award /
Change Letter").
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Use SSPS Code 2964 ("WCCC Reimbursement") to
reimburse the consumer.
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EXAMPLE 1
Sarah incurred one month's full-day, full-time child care expenses at the provider's usual rate of $30 per day or $660 per month. The State maximum, based on the age of the child and type and location of care, is $24 per day or $528 per month. With help from her family, Sarah paid the entire amount herself. Based on her income, her copayment would have been $15.00 per month. The State reimbursement to the consumer is calculated:
| $528 |
|
Maximum to be reimbursed and/or paid retroactively |
| -$15 |
|
Sarah's copayment obligation |
| $513 |
|
State reimbursement to the consumer |
| Authorize the reimbursement on the SSPS
authorization (DSHS 14-154) with the parent listed as the Provider and Payee. |
| Auth. #1 |
|
Line 1 |
02964 |
$513.00/EA |
01 |
$513.00 |
|
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EXAMPLE 2
Same as example #1, except Sarah paid $200.00 and owes the remaining balance of $460.02 to the provider:
| $528 |
|
Maximum to be reimbursed and/or paid retroactively |
| -$15 |
|
Sarah's copayment obligation |
| $513 |
|
| |
|
| $513 |
|
| -$460.02 |
|
State retroactive payment to the provider (Auth #2) (See "Provider Reimbursements" below) |
| $52.98 |
|
State reimbursementto the consumer (Auth#1) |
| Auth #1 |
|
Line 1 |
02964 |
$53.00/EA |
01 |
$53.00 |
| Auth #2 |
|
Line 1 |
02951 |
$20.91/DA |
22 |
$460.02 |
|
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EXAMPLE 3
Jane discovered we incorrectly determined her copayment for the past 7 months. It was set at $100.00; it should have been $50.00. After verifying Jane paid the full $100.00, you can establish a reimbursement to Jane for the difference of $350.00 ($50.00 X 7 months).
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EXAMPLE 4
Keesha is receiving WCCC but had to use a provider who would accept her child while the child was sick for 5 days. Keesha had to pay upfront for the 5 days of care and is now asking to be reimbursed. The sick child care provider is licensed but does not accept subsidies. DSHS cannot reimburse Keesha for the care she paid out of pocket. We cannot make reimbursements if a parent uses a provider who does not accept subsidy payments or who is not an eligible provider.
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PROVIDER REIMBURSEMENTS
Providers who ask to be reimbursed for child care are usually asking to be paid for services already provided. The three main types of provider "reimbursements" are those that were:
- Authorized and the service was provided within the last 12 months-can be authorized and should invoice and pay normally;
We make payment through the usual authorization or payment adjustment processes. Please see the SSPS manual for more information on payment adjustments.
When providers request payment for retroactive child care, verify the following before making payment:
-
The parent and child were
eligible for WCCC during the requested time period,
-
Payment was not previously
made for the requested service, and
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Whether a copayment was
already established for the requested time period.
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EXAMPLE
On 12/15 you verify:
ABC child care provided care for Jack for the month of November but he was not on the invoice; The family was eligible for WCCC during November; and The payment time frame is not more than 365 days prior to 12/15.
Establish a new authorization through WCAP and
SSPS for the November care. Remember to include the copayment if the
parent has not already paid it for November. |
Never authorized and the service was provided over 12 months ago needs to be authorized and a payment adjustment form completed; or Authorized and the provider underbilled needs a payment adjustment form completed.
Correcting an Under-Claim:
The system created an invoice and the payee returned it for payment. However, the payee claimed less than was authorized, invoiced, and provided. Indicate the under-claim by checking box 1a on the Payment Adjustment form. Enter only the additional amount that needs to be paid in the Adjusted Amount space on the Payment Adjustment form. Attach verification that the provider under-claimed the services to the Payment Adjustment form. Verification can be either screen prints of the SSPS payment screens or copies of payment records printed from COLD.
For Invoiced Services More Than 12 Months Old:
We must first authorize the services in SSPS. The service will not pay but it must be authorized in order to have an authorization number. When completing the Payment Adjustment form, check box 1b on the Payment Adjustment form and attach a copy of the DSHS 14-159 authorization form to the Payment Adjustment. The 14-159 can be either a screen print of the authorization after it has been input and an authorization number has been assigned by the system, or a copy of the actual 14-159 turnaround. Handwritten 14-154s (or copies of handwritten 14-154s) are not acceptable as verification.
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EXAMPLE
On 8/10 XYZ child care provider calls and reports the following two situations:
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They claimed 2 units for Sam for July instead of 22 and they want to be "reimbursed" (paid) for the other 20 units (this is an "underclaim").
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They just discovered a missing payment for Trisha for the month of January (more than 365 days (12 months) old).
Process payment adjustments forms DSHS 07-055 for both cases.
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NOTE: |
SSPS will invoice and pay for authorizations for up to twelve months in the past. The authorizations must be opened/closed, as SSPS will not invoice/pay for an expired service if the authorization is still open. (service end date prior to current month)
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NOTE: |
There is no record of payments made via the Payment Adjustment process in either the SSPS on-line payment inquires or in the SSPS payment history reports available in COLD. Therefore, you must document the payment clearly in the case record.
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