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