ParaRegs-Medi-Cal-Budgeting-and-Underpayments
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505 Retroactive coverage / Effective date of
eligibility |
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Code |
Effective |
ParaReg Text |
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The
Medi-Cal maintenance need for an MFBU of ____ persons is $___. (§50603; All- |
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502-2 |
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The
maintenance need for a member of the MFBU in Long-Term Care shall be $35
(except for individuals with therapeutic wages). (§50605(a)) |
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502-3 |
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A
Long-Term Care (LTC) patient shall retain an amount of income for upkeep of a
home in addition to the LTC maintenance need if the spouse or family of the
LTC patient is not living in the home, the home is being maintained for the
return of the LTC patient, and there is a verified medical determination that
the LTC patient will return home within six months of the date that LTC
patient status was established. The amount of the upkeep allowance is 133 and
1/3 percent of the income in kind value of housing for one person if the
patient has been living alone in the home or 133 and 1/3 percent of the
income in kind value of housing for 2 persons, divided by 2, if the home is
shared with persons for whom the patient has no legal responsibility for
support. (§50605(b)) |
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502-4 |
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When
an MFBU does not include a person in Long-Term Care, net nonexempt income is
determined for members of the MFBU. From the net income, the appropriate
maintenance need is subtracted in order to determine the share of cost.
(§50653(a)) |
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502-5 |
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As a
result of the final settlement in the Johnson
v. Rank lawsuit, Medi-Cal
beneficiaries in Long-Term Care (LTC) facilities are allowed to deduct the
cost of necessary medical or remedial drugs or services not covered by
Medi-Cal from their Share of Cost (SOC). Effective October 1, 1989, these LTC
beneficiaries must have a current physician's prescription or order for any
drug or service which is to be used to meet the SOC. (All-County Welfare
Director's Letter (ACWDL) No. 89-54, July 24, 1989) |
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When a
change in income or circumstances results in a decrease in the SOC and is
reported by a beneficiary in a timely manner, the county is to recompute the
SOC for the month in which the change occurred and shall provide the
beneficiary the option of having an adjustment made in the future amount of
the SOC or processing a corrected Form MC 177S, or Medi-Cal card with a share
of cost, for the month in question. The amount of any adjustment shall be
based on those months in which income in excess of the correct SOC was paid
or obligated toward medical bills. (§50653.3(a)) |
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504-1A |
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In
1994, the Department of Health Services began converting from paper Medi-Cal
Cards, issued monthly, to the plastic Benefits Identification Card
(BIC). A new card is no longer issued
to every Medi-Cal eligible person on a monthly basis. (All-County Welfare Directors Letter
(ACWDL) No. 96-06, February 1, 1996) As
of (Denti-Cal Bulletin, Vol. 13, No. 13, June 1997) |
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504-2 |
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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. |
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In
addition to the period of eligibility specified in §50701, an applicant shall
be eligible for Medi-Cal in any of the three months immediately preceding the
month of application or reapplication if all of the eligibility requirements
are met in that month. (§50197(a), replacing §50710(a), effective |
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505-1A |
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The beginning date
of eligibility for persons applying only for Medi-Cal, whose eligibility has
not yet been determined, shall be the first day of the month of application
if all eligibility requirements of the appropriate Medi-Cal Program are met,
or the first day of the month subsequent to the month of application during
which the eligibility requirements of the appropriate Medi-Cal Program are
met. (§50193(c), replacing §50701(c),
effective |
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505-2 |
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The
applicant is not entitled to three-month retroactive coverage if the
applicant was previously denied Medi-Cal for the month in question, unless
the application was denied because of county error or a failure to cooperate
when that failure, or the applicant's subsequent failure to reapply, was due
to circumstances beyond the control of the applicant. (§50197(a)(3),
replacing §50710(a)(3), effective |
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505-3 |
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A
person or family applying for retroactive Medi-Cal must submit a completed
application to the county if the application is for retroactive coverage
only. Such request made in conjunction with, or after an application for
public assistance or Medi-Cal, must be made on the application form, on the
Statement of Facts or by submitting a written request. The application must
be submitted within one year of the month for which retroactive coverage is
requested. (§50148) |
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505-4 |
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Actual
income is used in computing the SOC in retroactive Medi-Cal months. Income
verification used to determine current month eligibility on the MC 210 can be
used to determine income as long as "no change" is reported by the
beneficiary on the MC 210A. (All-County Welfare Directors Letter No. 02-43, |
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Pursuant
to the Hunt v. Kizer court order, as implemented by
the CDHS, individuals are allowed to apply medical bills from previous months
(old medical bills) toward their current month's SOC provided these old
medical bills were unpaid at the time they were submitted to the county.
Individuals are also permitted to save old or current medical bills and apply
them as old medical bills toward their SOC in a future (later) month,
provided these old medical bills remain unpaid. Individuals are allowed to
use credit card or collection agency statements as evidence of medical
expenses. |
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506-5 |
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The CDHS has defined the following terms for purposes of
the Hunt v. Kizer procedures. Current Month: This refers to the current calendar month. Future Month: A future month is any month which is future
to the current month. Previous Month: A previous or past month is any month prior
to the current month. Current Medical Bills: The term "current medical bill"
refers to a medical bill which is/was incurred in the same month (month of
eligibility) for which it will be applied toward the individual's Share of
Cost (SOC). As used in these
procedures, the term "current medical bill" does not refer to the
bill's chronological age. Old Medical Bills: The term "old medical bill,"
refers to a medical bill which was incurred in a month previous to the month
for which it will be applied toward the individual's SOC. Old and current medical bills are
sometimes treated differently and subject to different requirements for
purposes of determining whether they can be applied toward the SOC. The most notable difference is that current
medical bills may be applied toward the SOC whether unpaid or paid, while old
medical bills must be unpaid before they can be applied toward the SOC. Month In Which A Medical Bill Is
Incurred: A medical bill is
incurred on the date the medical service or drug is provided. The month in which a medical bill is
incurred is the month in which this date of service falls. Medical Bills Spanning Two Or
More Months: In some instances, a
medical bill will show a single medical expense for a medical service, such
as a hospital stay, which was rendered over multiple days and therefore shows
multiple dates of service. A medical
bill showing such a multiple-day medical expense spanning more than one month
is incurred in each month containing one or more dates of service for that
expense. When a medical bill spans two
months, a portion of that bill is incurred in each month. If an individual submits such a medical
bill to the county, the county must determine how much of the bill was
incurred in each month. To calculate
the portion of the medical expense that was incurred in the first month the
county should first calculate the daily charge for the medical service by
dividing the medical expense for that service by the number of dates of
service for that expense, and then multiply the daily charge by the number of
dates of service falling within the first month. Similarly the amount of the bill incurred
in the second month is the daily charge multiplied by the number of days of
service in the second month. Unpaid Old Medical Bills: Unpaid old medical bills are old medical
bills which are unpaid at some time in the month in which they are submitted
to the county. If a portion of the old
medical bill has been paid, the unpaid portion may still be applied toward
the individual's SOC. Medical Bills and Medical
Expenses: Medi-Cal can accept for
application toward a individual's SOC only medical
bills for bona fide medical expenses.
Expenses for medically-related services qualify as bona fide medical
expenses if the service was rendered by a State-licensed health-care provider. Expenses for medically-related
equipment, supplies or drugs qualify as bona fide medical expenses if the
equipment, supply-item or drug was: 1. Prescribed by a physician as
necessary to treat a medical condition and; 2. Is customarily considered by the medical
profession as primarily for health care and medical treatment and; 3. Is intended, and will be used, solely
for the health care and medical treatment of the individual. Medi-Cal presumes that medical
expenses for drugs and supplies which are available only through a
prescription are necessary to treat a medical condition and that expenses for
these items are therefore bona fide medical expenses. This presumption does not apply to
medically-related equipment, drugs and supplies which a physician has
prescribed but which are available without a prescription. For drugs, supplies, and medical equipment
which have been prescribed, but which are available without a prescription,
counties may require that the individual obtain a statement from the prescribing
health-care provider attesting that each of the three above- numbered
requirements are satisfied. The
statement must include a short description of the condition being treated and
must name the drug, supply, or medical equipment which the physician has
prescribed. If the county is uncertain whether
the drug or other item is available without a prescription, the county may
require that the individual obtain a statement from the provider stating
either that the item or drug is available only through a prescription, or
attesting that each of the three above-numbered requirements is satisfied. The county may disallow the
application toward meeting the SOC of a medical expense for a drug or other
item which is available without a prescription despite a provider's statement
attesting to the three above-numbered items if the provider's statement is
contrary to common sense. Remedy: The word
"remedy" is used in these procedures to denote certain benefits
belonging to the Medi-Cal individual which have
arisen as a result of the Hunt v Kizer lawsuit. (MEPM §10R-1
through 4) |
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506-6 |
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Under Hunt v. Kizer procedures, an individual may
apply an "old medical bill" toward his/her SOC when all of the
conditions below are satisfied. 1. The old medical bill, or the portion
of the old medical bill, which will be applied toward the SOC was unpaid at
some time in the month of its submission to the county. 2. The bill is not more than four years
old as of the date of its submission, unless it falls under one of the exceptions
to the Statute of Limitations set forth in §V. 3. The old medical bill satisfies the
qualifying criteria (§IlI.A of these procedures),
verification requirements (§III.B of these procedures) and other applicable
conditions discussed in these procedures. 4. An old medical bill submitted for
application toward the SOC must not have previously been applied toward the
SOC and must not have been for a medical expense which is subject to payment
by the Medi-Cal program. Individuals may also save and accumulate
unpaid medical bills from a current month and then submit these bills as old
medical bills toward their SOC in a later month. An old medical bill may also
be applied toward a past month IF the bill was incurred previous to that past
month and IF the individual had not already met his/her SOC in that past
month. These bills cannot be applied
to months more than 12 months previous to the month of their submission
(months for which a Letter of Authorization would be necessary) unless the
individual could qualify for a Letter of Authorization on grounds of
administrative error. (MEPM §10R-4, 5) |
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506-7 |
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All the criteria which a medical bill must satisfy (under Hunt v. Kizer) before the county can apply
the bill toward the SOC, set forth below, apply to UNPAID
OLD medical bills. Criteria 3-6 apply to CURRENT medical bills. 1. The old medical bill must be unpaid
at some time in the month of the bill's submission to the county (i.e., the
bill must not have been paid previous to the month in which it is submitted). 2. The old medical bill is less than
four years old as of the date of the bill's submission, with certain
exceptions. 3. That portion of the old or current
medical bill for which a third party is liable must first be subtracted from
the amount billed to the individual. 4. The portion of a current or old
medical bill previously used to meet a Medi-Cal SOC may not be re-applied
toward the SOC. 5. The current or old medical bill must
be an original bill, an authenticated copy, or an acceptable substitute. 6. The current or old medical bill must
satisfy the list of verification requirements. If completely paid previous to the
month of their submission, unpaid old medical bills cannot be applied toward
the SOC. If partly paid previous to the month of their submission, only the
portion of the old medical bill which remains unpaid in the month of
submission can be applied toward the SOC. Current medical bills can be applied
toward the SOC whether paid or unpaid (provided they meet other applicable requirements.) (MEPM §10R-5, 6) |
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506-8 |
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Current and old medical bills applied towards an
individual's SOC (under Hunt v. Kizer) must contain certain items of
information. These verification
requirements apply both to current medical bills and to old medical bills,
except where noted. The verification requirements which must be satisfied
are: 1. Current and old medical bills must
show the name and address of the provider who provided the service. 2. Current and old medical bills must
show the name of the person who received the medical service. 3. Current and old medical bills must
contain a short description of the medical service received. 4. Current and old medical bills must
show a "Procedure Code" (a medical reference number). 5. Current and old medical bills must
show either the provider's Medi-Cal provider identification number, taxpayer
identification number, or provider license number. 6. Current and old medical bills must
show the date(s) the medical service was provided. 7. Current and old medical bills must
show the date on which the bill was issued. If the bill is an unpaid old
medical bill, its billing date must be within 90 days of the date the bill is
received by the county. 8. Current and old medical bills must
show the amount owed solely by the individual and not subject to third party
coverage. If the individual has other health care coverage, the amount billed
solely to the individual may be demonstrated by a bill which shows the total
amount of the bill and a separate amount billed to the individual. Some of the numbered verification
requirements listed above may be supplied by the individual in a sworn
statement (Section VII of these procedures) if they are missing from the
medical bill. (MEPM §10R-6, 7) |
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506-12 |
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When a
person retroactively establishes property eligibility, under |