DPSS ePolicy

 To convert existing policy to new webpage – No concept changes.

Any Medi-Cal applicant or beneficiary having medical expenses incurred and unpaid must be allowed to use these medical expenses to reduce any current or future Share of Cost (SOC), if acceptable documentation of the unpaid expense is provided.
 
Beneficiaries may also save old or current medical bills and apply them toward their SOC in a future month, provided the old medical bills remain unpaid.
 
Old medical bills are not acceptable if they are fully paid prior to the month of the submission. Only any unpaid portion may be applied toward a SOC adjustment.
 
Note: An old medical bill may not be accepted if it was paid by the beneficiary in a previous month and then refunded by the provider in the month it is submitted to the eligibility worker (EW).
 
Additionally, beneficiaries may submit current paid or unpaid medical bills to the EW to be applied toward the SOC.

Previous to the Hunt v. Kizer lawsuit, Medi-Cal (MC) recipients could apply only those medical expenses incurred in the same month toward a particular month's SOC.  MC recipients were not allowed to apply medical bills incurred in prior months (old medical bills) toward their SOC for a current month.  Nor could they save medical bills from current months to apply them as old, unpaid medical bills toward a future month's SOC.  In 1989, the above restrictions were eliminated due to the Hunt v. Kizer lawsuit.

Acceptable Medical Bills/Expenses

Acceptable medical bills and expenses are those which are rendered by a state licensed health-care provider.
 
When a beneficiary wish to adjust expenses for medically related equipment, supplies or drugs which have been prescribed but are available without a prescription, the EW may require a statement from the health care provider if the expense is questionable.  The provider’s statement must include:

• A short description of the condition being treated.
• The name of the drug, supply or equipment prescribed.

The old medical bill must be unpaid in the month of submission. A current billing (within the last 90 days) is presumed to be unpaid.

Unacceptable Medical Bills/Expenses

The medical bills or a portion of a medical bill which are unacceptable and cannot be used to meet or reduce a SOC are the ones paid by:

• A third party,
• Medicare,
• Medi-Cal, or
• Other private/group coverage.

Beneficiaries with Other Health Coverage (OHC)

A beneficiary with Other Health Coverage (OHC) can only reduce the SOC on medical expenses not covered by their insurance.  The medical bill must state the amount the beneficiary is obligated to pay. If the amount is unknown, the beneficiary must obtain a statement from the provider/insurer stating the following:

1. Total amount of the service given, and
2. The amount the beneficiary is obligated to pay.

Note: Interest or other finance charges accumulated on unpaid medical bills cannot be used to offset a SOC.

In-Home Supportive Services (IHSS)

Any out-of-pocket expenses for personal care services including IHSS can be used to meet and/or reduce a Medi-Cal SOC under Hunt vs. Kizer regulations.  If the out-of-pocket expenses are used to reduce the SOC, it cannot be used as an income deduction for the Medi-Cal budget.

These expenses do not need to be assessed by an IHSS Social Worker as long as the medical plan or prescription for personal care is specific.

Unpaid Bills

The beneficiary must be legally liable for the unpaid bills. This means:

• Bill is less than four (4) years old;
• There is a judgment from a formal judicial proceeding making the beneficiary liable;
• There is a contract extending the four (4) year statute of limitations; or
• Other reasonable written verification showing the beneficiary is still legally liable.

Any portion of the medical bill a third party is liable to pay must be subtracted from the medical bill.  In addition, any portion of the medical bill previously used to meet a SOC may not be reapplied to the SOC in a subsequent month.

The beneficiary must provide the EW with verification of the original billing statement before adjusting the SOC.  The billing statement must include the following:

1. Billing date within the last 90 days,
2. Name of the person(s) who received the service,
3. Short description of the service,
4. Procedure code for bills incurred after 1/1/1992,
5. Provider’s:
   
   • Federal Tax identification number,
   • Medical provider identification number, or
   • License number.
6. Date the medical service(s) was provided, and
7. Amount beneficiary is obligated to pay after any payments by a third party are subtracted.

Note: An original or any substitute billing statement which has been altered is not acceptable verification unless the bill has been updated by the provider and the provider has signed or initialed the notation.

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