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<THEAD>Code
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Effective
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ParaReg
Text</THEAD><TBODY>
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511-1A
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A
potential overpayment occurs when a beneficiary, or the person acting on the
beneficiary's behalf, has been informed verbally and in writing of the
responsibility to report completely and accurately all facts which would
affect eligibility or SOC, and to report any changes of those facts within 10
days. The beneficiary or the beneficiary's representative must also have
signed a certification for assistance, and then provided incorrect oral or written
information, or failed to report changes within 10 days, which would affect
eligibility or SOC. The beneficiary or representative must have had the
competence to report the incorrect or missing information.
No potential overpayment exists if the beneficiary or representative informed
the county of the relevant factual circumstances, or when the beneficiary or
representative failed to perform an act which is a condition of eligibility
if the failure is due to an error by the CDHS or the county department.
(§50781)
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511-1B
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A
potential overpayment occurs when a beneficiary, or the person acting on the
beneficiary's behalf, fails to report other health coverage and: (1) the
other coverage is of a type designated by CDHS as not subject to postservice reimbursement and the beneficiary failed to
utilize such coverage without good cause; or (2) the beneficiary has received
services for which Medi-Cal paid, and the beneficiary also claimed and
received payment through private health coverage. (§50781.5)
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511-2
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When
it appears that there may be a potential overpayment, the county is to
determine the correct eligibility status and SOC and, if a potential
overpayment has occurred, the county is to refer the matter to the CDHS.
(§50783)
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512-2
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Upon
receipt of a potential overpayment referral, the Department's Recovery
Section or the county unit contracted to collect overpayments shall determine
the amount of Medi-Cal benefits received by the beneficiary during the
affected period. When the potential
overpayment is due to increased SOC, the actual overpayment shall be the
lesser of:
(1) The actual cost of services received
in the SOC period which were paid by the Department; or
(2) The amount of the increased SOC for
the SOC period.
(§50786(a)(2)(B))
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512-3
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When
the potential overpayment was due to excess property, the actual overpayment
shall be the lesser of the actual cost of services paid by the Department,
and the amount of property in excess of the property limit. This excess
amount is determined by computing the excess property at the lowest point for
each consecutive month, and then using the highest
monthly amount to determine the overpayment. (§50786(a)(2)(A))
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512-3A
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While Principe v. Belshé requires counties to permit
applicants to retroactively establish property eligibility by spending excess
property on qualified medical expenses, the Principe case does not modify overpayment procedures for those
Medi-Cal beneficiaries who have received Medi-Cal benefits, and then are
discovered to have excess property during a month or months in which they
received Medi-Cal. Overpayment recovery is governed by the regulations, as
set forth in §§50781 through 50787. (All-County Welfare Directors Letter No.
97-41, October 24, 1997)
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512-4
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State
law provides that no liability for a Medi-Cal overpayment shall result when a
recipient failed to perform an act constituting a condition of eligibility
when the failure was caused by an error made by DHS or by the county. In
addition, when the beneficiary has accurately and completely reported within
his or her competence facts material to a correct determination of
eligibility and share of cost, there shall be no liability for any resulting
overpayment. (Welfare and Institutions Code (W&IC) §14009(d))
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512-5
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For purposes
of calculating Medi-Cal overpayments, any managed care capitation rates are
treated as covered Medi-Cal services. (All-County Welfare Directors Letter
No. 01-38, July 12, 2001)
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513-1
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The
CDHS or county unit contracted to collect overpayments may take other
collection actions as permitted under state law against the income or
resources of the beneficiary or the income and resources of any person who is
financially responsible for the cost of the beneficiary's health care in
accordance with §§50088, 50163, and 50185. (§50787(c))
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514-1
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The CDHS or county unit contracted to collect overpayments shall
demand repayment of actual overpayments in accordance with procedures
established by CDHS. (§50787(a))
The CDHS or county unit shall inform the beneficiary, or the person acting on
the beneficiary's behalf, in writing, of the overpayment and of the right to
a state hearing on the overpayment. If the person requests a state hearing on
the overpayment, collection action shall be suspended until a final decision
has been rendered in accordance with §50953. (§50787(b))</TBODY><TFOOT></TFOOT>
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