DPSS ePolicy

Terms and Descriptions

Good Cause

When there are Domestic Violence (DV) situations or geographical barriers to care.

Geographical Barrier

When the other health plan is limited to a specific geographic service area and the applicant/beneficiary lives more than 60 miles or 60 minutes travel time from the specified provider(s).  In this situation, the OHC is considered unavailable.

Category and Acceptable Verifications

 Add or Modify OHC

 The following are acceptable verifications:

1. Beneficiary’s health plan policy;
2. Beneficiary's membership identification card.

Note:  Information may include member’s name, health plan name, and policy or medical record number.

Terminate OHC

The following are acceptable verifications:

1. A payroll or pension check stub showing the deduction for private insurance has stopped;
2. An Explanation of Benefits from the insurance carrier or employer showing the date the policy terminated;
3. An affidavit signed by the MC applicant/beneficiary or their authorized representative stating he/she no longer has or never had OHC.  The affidavit should include the date the policy terminated, if known.  The affidavit may also be used, when a custodial parent or guardian cannot verify termination of an absent parent’s insurance.