Okla. Stat. tit. 12, § 12-994.2: 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.