Article 15 Section 1 Other Health Coverage OHC Table of Contents TITLE MPG CITE OHC General Information 150101 Responsibility for Reporting 150102 OHC Reporting Terminations Changes and Modifications 150103 Medicare HMO Premium Payments 150104 Health Insurance Premium Payment HIPP 150105 Employer Group Health Plan EGHP 150106 Resources RESOURCE TITLE Desk Aid Desk Aid 41 How To Access And Complete Form DHCS 6172 OnLine Desk Aid 42 How To Add or Remove OHC Desk Aid 43 Samples Of When Not To Report OHC 150101 Introduction A Billing and Payment MediCal applicantsbeneficiaries are required to apply for andor retain any available health coverage when no cost is involved The MediCal program is designed by law as the payer of last resort for health care servicesbenefits Health insurance carriers are obligated to reimburse the MediCal program for the cost of any health care services received by a beneficiary when they are covered under the terms of an insurance policy Money collected by MediCal from insurance carriers is used to pay for health care benefits MEM PROC 15A MPG LTR 325 1195 B Cost Avoidance vs Post The state has two methods for utilizing OHC information for MediCal beneficiaries ACWDL 9482 ACWDL 9626 Recovery Method Billing Process Cost Avoidance The service provider must bill the OHC provider prior to billing MediCal NOTE Claims for beneficiaries with cost avoidance coverage will not be paid by MediCal without an Explanation of Benefits EOB from the OHC provider Post Recovery MediCal bills the OHC provider after paying the service provider DHCS places the OHC method information on MEDS as follows Code Type Source Cost Avoidance From information matched with health insurance companies Post Recovery From information received through CalWIN ACWDL C When the worker determines that the use of a OHC code is 9138 Effective appropriate the effective date of the OHC code is determined as 9716 Dates of OHC follows 9138 Codes Type Effective Date New Application First of the month of eligibility Redetermination Future month MPG LTR 350 0396 150102 Responsibility for Reporting ACWDL A Counties shall no longer add OHC records to MEDS except under the 1312 When to following conditions Report The applicantbeneficiary provides information that the OHC they have is not on the list of Current Trading Partners found at httpdhcscagovOHC The applicant or beneficiary has OHC that is not found in MEDS and wants their OHC added to their record MPG LTR 796 0713 ACWDL B Staff will not request an addition for OHC if the addition 1312 When Not to Endangers a beneficiary Report OHC Creates a barrier to care ACWDL 1312 C Documentatio record Members name MPG LTR 796 0713 D Repayment of Insurance Reimburseme nt Applicantbeneficiaries must report and repay MediCal for services MEDIL I 1205 received under MediCal but reimbursed by their insurance provider The worker will instruct the applicantbeneficiary to forward reimbursement payments to California Department of Health Care Services Third Party Liability Branch MS 4719 PO Box 997421 Sacramento CA 958997421 Beneficiaries should endorse checks from insurance carriers as follows For Deposit Only to Health Care Deposit Fund Name of Payee party to whom the check is made payable MediCal Identification Number of Beneficiary this may be a person different than the one who received the check Payment must be signed by either the payee or hisher agent The applicantbeneficiary must enclose with the check the following information Dates of service Providers name Daytime phone number where they can be reached MPG LTR 762 0912 150103 OHC Coding Terminations Changes and Modifications C Verifications for Removal of OHC To ensure that MediCal is the payer of last resort staff must verify ACWDL 1312 that OHC terminated for the applicant or recipient whose OHC ended or who never had OHC prior to removing the OHC code from MEDS The following is a list of acceptable verifications A payroll or pension check stub that shows deductions for private health insurance have ended An affidavit see MPG 150103D for details OHC issues MPG LTR 796 0713 F OHC for Good Cause ACWDL To bypass an OHC code an applicantbeneficiary must present good 1312 cause Below are examples of good cause Geographic barrier to care Domestic violence situations outlined in Desk Aid 42 How To Add or Remove OHC and note the HIS record carrier match list follow the instructions on Desk Aid 42 How To list in the comment field MPG LTR 796 0713 150104 Health Insurance Questionnaire A State Payment of Medicare HMOs Increase Premium Amounts Effective January 1 2001 DHCS began paying Medicare HMO ACWDL 0128 premium increases not covered by Medicare for certain MediCal beneficiaries enrolled in selected Medicare HMO Plans TPL determined that it would be more cost effective to have MediCal pay the increased HMO premiums for eligible beneficiaries receiving both MediCal and Medicare rather than have them disenroll and obtain their medical care on a feeforservice basis A Medicare beneficiary is eligible to have their increased Medicare HMO premium paid by the State if heshe meets the following criteria A fullscope MediCal beneficiary including both SOC and no SOC beneficiaries Enrolled in one of the Medicare HMO plans affected by this change Enrolled in a plan that includes both brand name and generic drugs Note Beneficiaries of QMB SLMB or QI Programs who are not receiving MediCal are not eligible to have the increased Medicare HMO premium paid by the State MPG LTR 449 0501 B Affected Health Plans Beneficiaries who meet the eligibility criteria defined in MPG 150104A and belong to the following Medicare HMOs will have the increased premium paid by the State Blue Shield Blue Cross Health Net Pacificare Kaiser ACWDL 0128 MPG LTR 449 0501 C Listing of Eligible Medicare Beneficiaries DHCS compiles a monthly listing identifying Medicare beneficiaries ACWDL 0128 who will have their increased Medicare premium paid by the State The listing entitled Medicare HMO Members Premiums Paid by MediCal is produced for each county in alphabetical order by the beneficiarys last name This report will be distributed to FRCs with granted MediCal staff to confirm the premium payment when responding to beneficiary inquiries Medicare beneficiaries with questions regarding their payment status may call the TPL toll free number 866 2279863 MPG LTR 449 0501 D Deductions Medicare HMO premiums will be treated as outlined in MPG ACWDL 0128 100603M and with the following additions The increased Medicare HMO premium will be treated as a health insurance deduction if the Medicare beneficiary provides proof that heshe is paying the premium and the individual is not identified on the listing The increased Medicare HMO premium will be removed as a health insurance deduction if information is received that the State is paying the premium All case action taken because of the increased Medicare HMO premium must be documented in case comments MPG LTR 449 0501 150105 Health Insurance Premium Payment HIPP A DHCS is authorized to pay health coverage premiums on behalf of ACWDL 9023 Overview medical beneficiaries through the Health Insurance Premium Payment 9572 HIPP Program whenever it is cost effective Paying these premiums 0925 for high cost medical users results in reduced MediCal costs DHCS 6172 Information from the DHCS 6172 is used to help DHCS evaluate for HIPP DHCS will notify the county via email if it will be paying the health care premiums When the county is notified that the beneficiary has been accepted to the HIPP program the worker will review the SOC and recompute the budget it if necessary MPG LTR 796 0713 B HIPP Qualifying Factors A person is potentially qualified for HIPP if There is current MediCal eligibility There is a high cost medical condition for which the average MediCal covered monthly cost is twice the amount of the monthly health ACWDL 9108 0902 9515 9571 insurance premium or the medical condition is one of those listed in Appendix E There is a current private or group health insurance coverage or COBRA continuation or a conversion policy in effect or available The policy does not exclude the high cost medical condition The premiums are not the responsibility of an absent parent There is no enrollment in a MediCal related prepaid health plan The clients health insurance policy must not be issued through the California Major Risk Medical Insurance Board 150106 Employer Group Health Plan EGHP A Effective January 1 1991 OBRA 90 mandated that states pay health Overview insurance premiums deductibles and copayments for MediCal recipients who are eligible for enrollment in an EGHP when it is cost effective In order to qualify for the EGHP program the client must meet all the conditions listed in MPG 150105B above and the health insurance must be available through an employer The state may also pay only the premiums for a nonMediCal eligible if the MediCal eligible persons enrollment in the health plan is dependent on the nonMediCal persons enrollment