Medi-Cal Card
Processing
ParaRegs-Medi-Cal-Beneficiary-Cards
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520 Benefits
Identification Cards |
523 BURU
/ Restricted use cards 526 Share of cost (Beneficiary obligating /
paying) |
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Effective |
ParaReg Text |
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The Medi-Cal card shall be
authorization for the person named on the card to receive those Medi-Cal
services for which the person is eligible. (§50733(a)) |
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The county department may issue
current or past Medi-Cal cards, as limited by §50746, to all Medi-Cal
eligibles who do not have a share of cost, who are not enrolled in a
comprehensive Pre-paid Health Plan for which a card is requested, and who did
not receive a Medi-Cal card. (§50743) |
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The county department shall not
provide a Medi-Cal card or request that a Medi-Cal card be issued by the
Department to any Medi-Cal beneficiary more than one year subsequent to the
month of service, unless one of the following conditions is met: (1) A
court action requires that a Medi-Cal card be issued. (2) An adopted state hearing decision or
other administrative hearing decision requires a redetermination of
eligibility which results in the beneficiary's entitlement to a Medi-Cal
card. (3) An adopted state hearing decision
states that, due to county department or Department administrative error, a
Medi-Cal card for a month was not received by the beneficiary. (4) The
Department requests that the Medi-Cal card be issued. (5) The county department determines that
an administrative error has occurred. (§50746(a)) |
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522-2 |
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For purposes of issuing a Medi-Cal
card more than one year subsequent to the month of service, a county
administrative error shall include, but is not limited to: 1. The County Welfare Department failed
to approve a Medi-Cal application by a potentially eligible individual due to
legitimate errors made in the course of determining eligibility (e.g., an
applicant was incorrectly denied and did not file an appeal, or an
applicant's file was misplaced so eligibility was never determined). 2. The county or MEDS system showed an
incorrect beneficiary address for the month of request. 3. The county never sent the original MC
177 to the State, or the original MC 177 is still in the case file after
being returned by the State for the county to correct. 4. The county issued a card within one
year but it was coded incorrectly and could not be used to bill for the
services rendered. (Medical Eligibility Manual, Procedures
Section 14E-1, as set forth in All-County Welfare Directors Letter No. 94-77,
October 11, 1994, interpreting §50746) |
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522-3 |
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When an applicant has excess
resources, counties must still complete eligibility determinations within the
time limits set forth in §50177. If the applicant provides verification at a
later date that excess property was spent on qualified medical expenses (up to
three years from the date of the Notice of Action denying benefits), the
county must rescind the denial if the applicant is otherwise eligible. |
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522-4 |
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Prior to 1994, all Medi-Cal
beneficiaries received a paper Medi-Cal card for each month in which the
beneficiary was eligible. In 1994, the
Department of Health Services (DHS) began converting from paper Medi-Cal cards
to the plastic Benefits Identification Card (BIC). Using the BIC, a provider can verify the
beneficiary's Medi-Cal eligibility through the Point of Service (POS)
Network. A new card is no longer
issued to every Medi-Cal eligible person on a monthly basis. (All-County Welfare Directors Letter No.
96-06, February 1, 1996) As of For purposes of determining whether
to issue a Medi-Cal card [which card no longer exists] more than one year
subsequent to the month of service, and no administrative error exists, but
extenuating circumstances exist beyond the beneficiary's or the county's
control, the county may contact the Medi-Cal Eligibility Branch for
assistance. Billing problems are not
by themselves considered an extenuating circumstance. Furthermore, beneficiaries who are sent to
collections after providing a Medi-Cal card should be told that W&IC
§14019.4 precludes a provider from billing the beneficiaries in these
situations. An example of extenuating
circumstances beyond a beneficiary's control would be a medical condition
that severely impaired his/her functioning.
Additionally, the beneficiary would need to describe how this reduced
function prevented him/her from giving the provider(s) the necessary
documentation of his/her Medi-Cal eligibility. The Medi-Cal Eligibility Branch will
evaluate whether a Letter of Authorization (LOA)/MC 180 can be issued
pursuant to §50746(a)(4), which provides for an LOA/MC 180 to be issued by
DHS request. The procedure to seek DHS
authorization for issuance in these cases is as follows: > The request must be in writing on
county letterhead. > It must list chronologically the
sequence of events in the processing of the case and the circumstances
surrounding the error. > It must carry the original signature
of a County Welfare Department Director or his/her DHS-approved designee
(photocopied signatures will not be accepted). > The request must be accompanied by
an original LOA/MC 180 for each provider.
However, in the event that one provider is billing for services for
more than one month, one original LOA/MC 180 is sufficient. > To insure proper use of this form,
please cross out any months/years that are not being requested or not being
used on the LOA for Medi-Cal billings. (Medi-Cal Eligibility Procedures Manual
§14E-2, 3) |
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A beneficiary who has been
determined by the Department to be misusing or abusing Medi-Cal benefits by
obtaining drugs or other services at a frequency or amount not medically
necessary may be subjected to utilization restrictions in any of the
following forms: (1) Prior
authorization for all Medi-Cal services. (2) Prior
authorization for specific Medi-Cal services. (3) Restriction to utilization of a
specific, beneficiary-or Department-selected pharmacy. (4) Restriction to a specific beneficiary-
or Department-selected primary provider of medical services. (§50793(a)) The restriction described in (a) shall be
for a period of two years from the effective date on the Notice of
Action. (§50793(d)) |
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523-2 |
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If the beneficiary who has been
determined to have abused or misused Medi-Cal benefits requests a hearing and
the request is received prior to the effective date of the action, the action
will not be taken until the hearing has been held and a final decision
rendered. (§50793(f)) |
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523-3 |
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Prescribed drugs shall be
limited to no more than six per month unless: Prior authorization is
obtained; the beneficiary is receiving care in a nursing facility; or the
drugs are prescribed for family planning. (Welfare and Institutions Code
(W&IC) §14133.22) |
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To meet the SOC, the provider
of services will certify that payment for services will be sought from the
patient and not from the Medi-Cal Program or a third-party insurer.
(§50657(a)(6)) |
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526-3 |
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Retroactive adjustment of the
SOC would be appropriate in situations where eligibility for a deduction is
determined at a later date. (Medi-Cal Eligibility Procedures Manual §12 C) |
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526-3A |
ADDED 3/07 |
California Code of Regulations, Title 22, Section 50653.3(c), discuss
the need to make adjustments when a person has been determined to have a
lower Medi-Cal SOC for a given month(s) than was originally computed. Welfare
and Institutions Code Paragraph 14019.3 speaks to provider return of payments
for services covered by Medi-Cal. Persons determined to be entitled to a
lower share of cost (SOC) have the option of: 1. Having future SOC amounts adjusted by
the county; or 2. Adjusting with providers, the amounts
obligated or paid to those providers to meet the overstated portion of the
original SOC. Medi-Cal Eligibility Procedures
Manual §12C, p. C1) |
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526-4 |
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When a person retroactively
establishes property eligibility, under |
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ADDED 11/05 |
In Conlan v. Bontá, the California Court of
Appeals, First Appellate District, the plaintiffs asked the Court to order
the CDHS to set aside fair hearing decisions which had denied requests to
order reimbursement to the plaintiffs for medical costs incurred while Medi-Cal
applications were pending. The applicants eventually had been granted
Medi-Cal, after they had paid their medical bills. The Court ordered CDHS to "ensure that Medi-Cal
recipients entitled to reimbursement for covered services during the
retroactivity period [i.e., before Medi-Cal was approved] are promptly
reimbursed." The court discussed the role of the ALJ and in the
Disposition required "... ALJs to determine what amounts, if any, each
petitioner is entitled to receive..." and order "direct reimbursement"
or allow CDHS "a reasonable period of time in which to implement new
procedures designed to effect such reimbursement." (Conlan v. Bontá (2002) 102 |
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527-2 |
ADDED 3/07 |
The CDHS has been ordered by the superior court in Conlan v Bonta and Conlan v Shewry to implement a Beneficiary Reimbursement process
enabling Medi-Cal beneficiaries to obtain reimbursement of paid out-of-pocket
expenses for Medi-Cal covered services received during specific periods of
beneficiary’s Medi-Cal eligibility.
These periods include 1) the retroactive period (up to three months
prior to the Medi-Cal application month; 2) the evaluation period (from the
time of the Medi-Cal application until eligibility is established), and 3)
the post-approval period (the time period after eligibility is established) A notice was sent out to current and former beneficiaries
indicating they may seek reimbursement for out-of-pocket medical or dental
expenses if they were eligible for Medi-Cal anytime since (ACWDL 07-01, January 12, 2007) |
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