reglab/statecodes huggingface dataset:
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50735 - Locations at Which Medi-Cal Card May Be Used

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Medi-Cal card shall be authorization
					 for payment for Medi-Cal covered services received in any California
					 county.
(b) The Medi-Cal card shall
					 be authorization for payment for Medi-Cal covered services provided outside
					 California in accordance with Section
					 51006.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50737 - Format of Medi-Cal Card

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Medi-Cal card issued by the Department
					 or by the county department in accordance with these regulations shall be used
					 to authorize services.
(b) The
					 Medi-Cal card for persons with no share of cost shall contain:
(1) Complete and accurate information
					 identifying the beneficiary, the program under which eligibility has been
					 established and other health care coverage entitlement.
(2) Valid month and year and whether it is a
					 past month Medi-Cal card.
(3)
					 Information on limited service or PHP status, if applicable.
(4) Two MEDI labels, if the card is a full
					 complement card.
(5) Proof of
					 eligibility (POE) labels.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50739 - Full Complement and POE Only Medi-Cal Cards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A full complement Medi-Cal card is one
					 which has POE labels and two MEDI labels. This type of Medi-Cal card shall be
					 issued to a beneficiary who is not enrolled in a PHP:
(1) As the initial card for the current month
					 of certification for Medi-Cal.
(2)
					 As the initial card for any month of a retroactive period during which there is
					 certification for Medi-Cal.
(3) As
					 a replacement card for a person who is entitled to and has requested a card,
					 has completed a Request for Medi-Cal Card or Additional POE Labels, form MC
					 110, and has not received a card.
(4) As a replacement card if the original was
					 incorrect or mutilated and was returned to the county department with both MEDI
					 labels intact.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50740 - Medi-Cal Cards for Restricted Medi-Cal Benefits to Certain Aliens

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An alien who is eligible for restricted Medi-Cal
						benefits, and who meets all other eligibility requirements, shall receive a
						Medi-Cal card which entitles him or her to program-covered services to treat an
						emergency medical condition as defined in section
						14007.5(d)
						of the Welfare and Institutions Code and section
						440.255 of title 42 of the Code of
						Federal Regulations, and pregnancy-related services, as defined in section
						1(g) of chapter
						1441 of the Statutes of 1988, and section
						440.255 of title 42 of the Code of
						Federal Regulations.
1. New
						section filed 11-14-89 as an emergency pursuant to section
						9 of chapter 1441 of the Statutes
						of 1988; operative 11-14-89 (Register 89, No. 48). A Certificate of Compliance
						must be transmitted to OAL within 120 days or emergency language will be
						repealed on 3-14-90.
2. New section refiled 3-8-90 as an emergency
						pursuant to section
						9 of chapter 1441 of the Statutes
						of 1988; operative 3-13-90 (Register 90, No. 12). A Certificate of Compliance
						must be transmitted to OAL within 120 days or emergency language will be
						repealed on 7-11-90.
3. Certificate of Compliance as to 3-8-90 order
						transmitted to OAL 7-5-90 and disapproved 8-6-90 (Register 90, No.
						42).
4. New section filed 8-23-90 as an emergency pursuant to
						section 9 of chapter 1441 of the Statutes
						of 1988; operative 8-23-90 (Register 90, No. 42). A Certificate of Compliance
						must be transmitted to OAL by 12-21-90 or emergency language will be repealed
						by operation of law on the following day.
5. Certificate of
						Compliance including amendment as to 8-23-90 order transmitted to OAL 11-20-90
						and filed 12-17-90 (Register 91, No. 5).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; and Section
						  9, Chapter 1441, Statutes of 1988.
						  Reference: Section
						  14007.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50741 - Medi-Cal Card Issuance by the Department

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Department shall issue a Medi-Cal
					 card to each person who is not enrolled in a comprehensive PHP and is any of
					 the following:
(1) Reported by the county
					 department as both eligible and certified for Medi-Cal and for whom the county
					 department is requesting that a card be issued.
(2) Reported by the Social Security
					 Administration as eligible for SSI/SSP.
(3) Certified for Medi-Cal by
					 BRU.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50742 - Limitations on Eligibility Reports and Card Issuance Requests Submitted by the County Department

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The county department shall not submit a report of eligibility to the
					 Department for a person for a given month, or request the Department to issue a
					 Medi-Cal card for a person for a given month, as long as any one of the
					 following applies to that person for that month:
(1) The county has information which requires
					 discontinuance of the person for that month.
(2) The person is subject to discontinuance
					 for the month due to loss of contact or noncooperation.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50743 - Medi-Cal Card Issuance by the County Department - No Share of Cost

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county
					 department shall issue a current or past month Medi-Cal card as limited by
					 Section 50746, to each person who meets
					 all of the following conditions:
(1) Is
					 eligible for SSI/SSP. The county department shall verify SSI/SSP eligibility by
					 obtaining information from the SDX data available to the county. If the SDX
					 data on the individual does not appear to be accurate or complete, proof of
					 eligibility shall be any of the following:
(A)
					 The SSI/SSP check for the month for which the card is requested.
(B) Documentation from the Social Security
					 Administration verifying eligibility.
(C) An SSI/SSP award letter received that
					 month.
(D) An approved Title XVI
					 emergency loan for that month.
(E)
					 Other proof of eligibility as specified by the Department.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50745 - Medi-Cal Card Issuance by the County Department - Share of Cost

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county
					 department may issue current or past month Medi-Cal cards, as limited by
					 Section 50746, to persons who are in
					 long-term care and have a share of cost which is less than or equal to the
					 monthly cost of care at the Medi-Cal reimbursement rate for the long-term care
					 facility unless the person in long-term care also has a spenddown of
					 property.
(b) The county department
					 shall issue current month Medi-Cal cards with MEDI or POE labels to persons
					 with a share of cost met by use of form MC 177S, if the person who requests the
					 card signs a form MC 110 which indicates a need for medical services prior to
					 normal anticipated receipt of a Department issued Medi-Cal card. In this case
					 the county department shall process form MC 177S in accordance with Section
					 50658.
(c) The county department may issue current
					 or past month Medi-Cal cards with POE labels only, as limited by Section
					 50746, to persons with a share of
					 cost if certification by the county department or BRU has occurred.
(d) The Director may order the suspension of
					 county issuance of Medi-Cal cards for persons with a share of cost, if the
					 Director determines that the cost of the procedure is exceeding allowable costs
					 under the Department's program for control of county department Medi-Cal
					 administrative costs.
(1) The Director shall
					 inform a county department of the suspension in that county, in writing, 30
					 days prior to the effective date of the suspension.
(2) The Director may reinstate the county
					 issuance of Medi-Cal cards for persons with a share of cost, if it is
					 determined that sufficient funds are available. Notification of the
					 reinstatement shall be in writing.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50746 - Limitation on Medi-Cal Card Issuance

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county department shall not provide a
					 Medi-Cal card or request that a Medi-Cal card be issued by the Department to
					 any Medi-Cal beneficiary more than one year subsequent to the month of service,
					 unless one of the following conditions is met:
(1) A court action requires that a Medi-Cal
					 card be issued.
(2) An adopted
					 State hearing decision or other administrative hearing decision requires a
					 redetermination of eligibility which results in a beneficiary's entitlement to
					 a Medi-Cal card.
(3) An adopted
					 State hearing decision states that, due to a county department or Department
					 administrative error, a Medi-Cal card for a month was not received by the
					 beneficiary.
(4) The Department
					 requests that the Medi-Cal card be issued.
(5) The county department has determined that
					 an administrative error has occurred.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50749 - Control of County Issued Medi-Cal Cards

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county department shall record every
					 Medi-Cal card issued or voided by the county department on the Control Log for
					 MC 301, form HAS 2007.
(b) The
					 county department may, with Department approval, use a substitute for form HAS
					 2007.
(c) The county department
					 shall account for stocks of Medi-Cal cards, as required by the
					 Department.
1.
						Amendment filed 8-8-80; effective thirtieth day thereafter (Register 80, No.
						32).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14017,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 14 - MEDI-CAL CARD USE AND ISSUANCE › Section 50751 - Report of Eligibles

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department shall compile a monthly report of all persons eligible for
					 Medi-Cal. This Report of Eligibles shall include all persons:
(1) Certified for Medi-Cal by the county
					 department and reported to the Department for issuance of Medi-Cal cards or
					 listing as enrolled in a PHP or PCCM plan.
(2) Certified for Medi-Cal and issued
					 Medi-Cal cards by the county department.
(3) With a share of cost. These persons are
					 reported as eligible but not certified for Medi-Cal.
(4) Certified for Medi-Cal and issued
					 Medi-Cal cards by Benefits Review Unit.
(5) Reported by the Social Security
					 Administration as eligible.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50761 - Other Health Care Coverage -General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A beneficiary with other health care coverage is not
						entitled to receive health care benefits and services under the Medi-Cal
						schedule of benefits until the other health care coverage available has been
						exhausted or denied for lack of service coverage. This requirement shall not,
						however, apply to beneficiaries covered under Medi-Cal capitated contracting
						arrangements except to the extent permitted under a contract.
1.
						Repealer and new section filed 6-28-89; operative 7-28-89 (Register 89, No.
						26).
Note: Authority cited: Section
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  10020,
						  14000,
						  14023,
						  14023.7
						  and
						  14490,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50763 - Beneficiary Responsibility - Other Health Care Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An applicant or beneficiary shall:
(1) Apply for, and/or retain any available
					 health care coverage when no cost is involved.
(2) Report to the county department any
					 entitlement to other health care coverage at the time of application,
					 reapplication, or redetermination; and report any change in entitlement no
					 later than 10 calendar days from the date the beneficiary was notified of the
					 change by the employer or insurer. The report shall include name of carrier,
					 policy and group numbers, and termination date, if available.
(3) Utilize other available health care
					 coverage prior to utilizing Medi-Cal coverage.
(4) Report to the county department services
					 received as the result of an accident or injury as specified in Section
					 50771(b), and
					 report the information specified in Section
					 50771(d)(2).
(5) Provide current other health care
					 coverage billing information to the provider at the time the service is
					 received. This information shall include the name of the other health care
					 coverage, policy and group numbers, and termination date, if
					 available.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50765 - County Department Responsibility - Other Health Care Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county
					 department shall:
(1) Determine the other
					 health care coverage in effect or available to an applicant or beneficiary upon
					 each determination or redetermination of Medi-Cal.
(2) Code the other health care coverage using
					 the coding system prescribed by the Department.
(3) Provide information regarding the
					 beneficiary's other health care coverage to the Department in the manner, form
					 and frequency requested.
(4) Notify
					 the Department that the beneficiary's other health care coverage has lapsed or
					 will lapse no later than five working day's following the receipt of such
					 information.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50769 - Department Responsibility - Other Health Care Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On the Medi-Cal card of beneficiaries who
					 have other health care coverage, the Department shall place an indicator code
					 to give notice to providers and beneficiaries that other health care coverage
					 must be utilized prior to billing the Medi-Cal program.
(b) The Department's fiscal intermediary
					 shall, as directed by the Department, deny provider claims submitted for
					 beneficiaries who have other health care coverage unless the claim is
					 accomplished by a notice of denial of non-coverage of service, termination of
					 coverage, or partial payment which is less than the Medi-Cal schedule of
					 benefits for the service or benefit provided. A provider of service may submit
					 a copy of the original notice of denial or explanation of benefits letter from
					 the other health care coverage. This notice or letter is valid for a period of
					 one year from the date the service was denied. The notice or letter must be
					 accompanied by a completed Medi-Cal claim form for the same service provided to
					 the beneficiary as indicated on the notice or letter.
(c) When Medi-Cal payment has been made
					 before the other health care coverage has been identified, the Department shall
					 recover payments from the parties having a legal obligation.
1.
						Repealer and new section filed 6-28-89; operative 7-28-89 (Register 89, No.
						28).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code, Reference: Sections
						  14023,
						  14023.7,
						  14124.90. Welfare and Institutions
						  Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50771 - Recovery of Third Party Payments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A beneficiary shall reimburse the
					 Department for any payment received for health care services which were paid by
					 Medi-Cal, if the payment received by the beneficiary is made by either of the
					 following:
(1) A federal or state
					 program.
(2) A legal or contractual
					 entitlement.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50771.5 - Determination of Good Cause for Refusal to Cooperate

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Good cause exists when cooperation is
					 against the best interest, as specified in (b) and (c) below, of an applicant,
					 beneficiary, or child for whom application is made or Medi-Cal received. These
					 regulations shall not preclude the county welfare department from contracting
					 with the district attorney for assistance in the investigation of good cause
					 claims.
(b) Good cause exists if
					 the applicant's or beneficiary's cooperation in securing medical support and
					 payments, establishing paternity, identifying and providing information
					 concerning liable or potentially liable third parties is reasonably anticipated
					 to result in serious physical or emotional harm;
(1) To the child for whom support is to be
					 sought;
(2) To the parent or
					 caretaker relative with whom the child is living as specified in (d)
					 below.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50772 - Veterans Aid and Attendance Payments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Veterans Aid and Attendance payment is
					 a veterans benefit designated to purchase aid and attendance services, and it
					 shall be considered a third party payment.
(b) A beneficiary who receives Veterans Aid
					 and Attendance payments shall be required to utilize this benefit in accordance
					 with the following:
(1) Beneficiaries in LTC
					 shall utilize the Aid and Attendance payments for LTC services prior to the
					 utilization of Medi-Cal benefits. Such utilization shall occur through the
					 share of cost process described in Article 12, that is, any amounts for
					 Veterans Aid and Attendance payments shall be added to the share of the cost
					 amount determined in Section
					 50653(a)(2)(F).
(2) Beneficiaries not in LTC shall utilize
					 the Aid and Attendance payments for the cost of IHSS prior to the application
					 of the income deduction specified in Section
					 50551.6.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50773 - Medicare Buy-In

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Medicare Buy-In is the payment of Medicare Part B premiums by the Department
					 under the California Medicare Buy-In agreement with the Social Security
					 Administration for Medi-Cal beneficiaries who are:
(1) Eligible under the SSI/SSP, Other PA or
					 MN program on the basis of age.
(2)
					 Eligible under the SSI/SSP, Other PA or MN program on the basis of blindness or
					 disability and also eligible for Medicare Part B in accordance with section
					 50775(a).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50775 - Medicare Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Persons eligible for both Medicare Part A (Hospital) and Part B (Outpatient)
					 benefits under the Social Security Act, Title XVIII, are persons or their
					 spouses who have the required number of quarters of covered employment, are
					 citizens of the United States or aliens legally present in the United States
					 for at least five years, and who meet at least one of the following:
(1) Are 65 years of age or over.
(2) Are entitled to disability, including
					 blindness, benefits for at least 24 consecutive months under Title II of the
					 Social Security Act, or Railroad Retirement program.
(3) Meet the requirements for the receipt of
					 Medicare as a patient with chronic renal disease.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50777 - Requirement to Apply for Medicare

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The following Medi-Cal applicants and
					 beneficiaries shall be required to apply for Medicare Part A:
(1) Any person 64 years and 9 months of age
					 or older.
(2) Persons applying for
					 Medi-Cal on the basis of blindness or disability.
(3) Persons who are receiving disability
					 payments under title II of the Social Security Act or Railroad Retirement
					 program unless the county can obtain verification of receipt of Social Security
					 title II disability payments in accordance with section
					 50167. In these instances Medicare
					 enrollment is deemed to be automatic beginning with the 25th month of receipt
					 of this benefit and application is not required.
(4) Persons receiving dialysis-related health
					 care services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 15 - OTHER HEALTH CARE COVERAGE AND MEDICARE BUY-IN COVERAGE › Section 50778 - Other Health Care Coverage Premium Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Department, in accordance with the period of
						eligibility as stipulated within the policyholder's contract, or in accordance
						with the period of eligibility as stipulated for continuation of coverage under
						federal law, shall pay the premiums to provide other health care coverage for a
						beneficiary with entitlement to such coverage when the estimated savings to the
						Medi-Cal program is 110% or greater than the premium costs. The estimated
						savings shall be determined by the Department by the review of either:
(a) Costs of covered medical services
					 received by the beneficiary during the preceding year, irrespective of the
					 payment source; or
(b) Estimated
					 annual cost of medical services for the treatment of the beneficiary's
					 pre-existing medical condition.
1. New
						section filed 6-28-89; operative 7-28-89 (Register 89, No. 26).
2.
						Amendment of section and NOTE filed 4-8-2010; operative 5-8-2010 (Register
						2010,
						No. 15).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Section
						  14124.91,
						  Welfare and Institutions Code; and
						  42 USC
						  1396b(a)(1).
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50781 - Potential Overpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 A potential overpayment occurs when all of the following conditions exist, as
					 limited by (b).
(1) A beneficiary, or other
					 person acting on the beneficiary's behalf, has been informed verbally and in
					 writing on the MC 210 cover sheet (9/91), and the certification in the
					 Statement of Facts (Medi-Cal), MC 210 (3/92), or on the cover sheet to and the
					 Application for Cash Aid, Food Stamps, and/or Medical Assistance (SAWS 1)
					 (9/90) CA 1/DFA 285-A1, or on the Important Information For Applicants and
					 Recipients For Cash Aid, Food Stamps and Medical Assistance (SAWS 2A) (5/92)
					 (Important Information) CA2/DFA 285-A2/MC 210, or on the Statement of Facts
					 Cash and Food Stamps - (JA2) (4/90) CA2/DFA 285-A2 of his/her responsibility to
					 report completely and accurately, facts required pursuant to Subdivision
					 1, Chapter 2, which would affect
					 eligibility or share or cost, and to report any changes in those facts within
					 10 days.
(2) A beneficiary or the
					 person acting on the beneficiary's behalf has completed and signed the Medi-Cal
					 Applicant/Beneficiary Understanding, MC 210 (9/91) cover sheet and the
					 certification in the Statement of Facts (Medi-Cal) MC 210 (3/92), or the
					 certification in the Statement of Facts Cash Aid and Food Stamps - (JA2) (4/90)
					 CA2/DFA 285-A2, or the certification in the Application for Cash Aid, Food
					 Stamps, and/or Medical Assistance (SAWS 1) (9/90) CA1/DFA 285-A1, or the
					 certification in the Important Information For Applicants and Recipients For
					 Cash Aid, Food Stamps and Medical Assistance (SAWS 2A) (5/92) (Important
					 Information) CA2/DFA 285-A2/MC 210 and has, within his/her competence, done any
					 of the following:
(A) Provided incorrect oral
					 or written information.
(B) Failed
					 to provide information required pursuant to Subdivision
					 1, Chapter 2, which would affect
					 the eligibility or share of cost determination.
(C) Failed to report changes in circumstances
					 regarding any information required pursuant to Subdivision
					 1, Chapter 2, which would affect
					 eligibility or share of cost within 10 days of the change.
(3) These facts, when considered in
					 conjunction with other information available on the beneficiary's
					 circumstances, would result in ineligibility or an increased share of
					 cost.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50781.5 - Potential Overpayments - Unreported Other Health Coverage

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A potential
					 overpayment occurs when a beneficiary, or the person acting on the
					 beneficiary's behalf, has knowingly failed to report other health coverage
					 under either of the following circumstances:
(1) The other health coverage is of a type
					 designated by the Department as not subject to post-service reimbursement, and
					 the beneficiary who fails to utilize such other health 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 care coverage.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50782 - Fraud

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Fraud occurs if an overpayment occurs and the beneficiary
						or the person acting on the beneficiary's behalf willfully failed to report
						facts as specified in Section
						50781(a) with the
						intention of deceiving the Department, the county department or the Social
						Security Administration for the purpose of obtaining Medi-Cal benefits to which
						the beneficiary was not entitled.
1.
						Amendment filed 12-30-81 as an emergency; effective upon filing (Register 82,
						No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days
						or emergency language will be repealed on 4-29-82.
2. Certificate of
						Compliance transmitted to OAL 4-23-82 and filed 5-12-82 (Register 82, No.
						20).
3. Amendment of section and NOTE filed 4-13-93; operative
						5-13-93 (Register 93, No. 16).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  11004,
						  14009,
						  14014
						  and
						  14016.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50783 - County Action on Potential Overpayment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The county department shall take the
					 following action when it appears that there may be a potential overpayment:
(1) Determine the correct eligibility status
					 and share of cost based on the correct income, property and other
					 circumstances.
(2) Determine
					 whether a potential overpayment exists in accordance with Section
					 50781.
(3) If a potential overpayment exists, refer
					 it to the Department or to the county unit contracting with the Department to
					 collect overpayments in accordance with the procedures established by the
					 Department.
(4) In those instances
					 where the potential overpayment is due to the willful failure to report facts
					 and there was a person acting on behalf of the beneficiary:
(A) Determine whether the beneficiary is
					 competent to handle his/her own affairs.
(B) If the beneficiary is competent, require
					 that the beneficiary act on his/her own behalf in the future.
(C) If the beneficiary is not competent,
					 refer the case to Social Services and/or the public guardian or conservator to
					 ensure that the beneficiary's interests are
					 protected.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50785 - Action on Overpayment - Department of Health. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 12-30-81 as an emergency; effective upon filing (Register 82,
						No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days
						or emergency language will be repealed on 4-29-82.
2. Certificate of
						Compliance transmitted to OAL 4-23-82 and filed 5-12-82 (Register 82, No.
						20).
Note: Authority cited: Section
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; Section
						  133.5, Chapter 102, Statutes of
						  1981. Reference: Sections
						  11004,
						  14009
						  and
						  14016.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50786 - Action on Overpayment - Department of Health Services or County Unit Contracted to Collect Overpayments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Upon receipt of a potential overpayment
					 referral, the Department's Recovery Section or the county unit contracted to
					 collect overpayments shall:
(1) Determine the
					 amount of Medi-Cal benefits received by the beneficiary for the period in which
					 there was a potential overpayment.
(2) Compute the actual overpayment in
					 accordance with the following:
(A) When the
					 potential overpayment was due to excess property, the actual overpayment shall
					 be the lesser of the:
1. Actual cost of
					 services paid by the Department during that period of consecutive months in
					 which there was excess property throughout each month.
2. Amount of property in excess of the
					 property limit during that period of consecutive months in which there was
					 excess property throughout each month. This excess amount shall be determined
					 as follows:
a. Compute the excess property at
					 the lowest point in the month for each month.
b. The highest monthly amount determined in
					 a. shall be the amount of the excess property for the entire period of
					 consecutive months.
(B) When the potential overpayment was due to
					 increased share of cost, the actual overpayment shall be the lesser of the:
1. Actual cost of services received in the
					 month(s) which were paid by the Department.
2. Amount of the increased share of cost for
					 the month(s) in which services were received which were paid by the
					 Department.
(C) When the
					 overpayment was due to excess property and increased share of cost, the actual
					 overpayment shall be a combination of (A) and (B).
(D) When the potential overpayment was due to
					 other factors which result in ineligibility the overpayment shall be the actual
					 cost of services paid by the Department.
(E) Potential overpayments, due to
					 beneficiary possession of other health coverage that is not subject to
					 post-services reimbursement, shall be processed by the Department to determine
					 and recover actual overpayments in all cases. The actual overpayment in such
					 cases shall be the actual cost of services paid by the Department which would
					 have been covered by private health insurance or other health coverage, had the
					 coverage been known to the Department. The actual overpayment shall not include
					 any costs which can be recovered directly by the Department from the health
					 insurance carrier or other source.
(3) Refer those cases where there appears
					 there may be fraud to the Investigations Branch of the Department.
(4) Take appropriate action to collect
					 overpayments in accordance with Section
					 50787.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50787 - Demand for Repayment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Department or the county unit contracted to collect overpayments shall
					 demand repayment of actual overpayments in accordance with procedures
					 established by the Department.
(b)
					 The Department or the county unit contracted to collect overpayments shall
					 inform the beneficiary, or the person acting on the beneficiary's behalf, in
					 writing, of the overpayment amount and of his/her right to a state hearing on
					 the overpayment in accordance with Section
					 50951. 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 Section
					 50953.
(c) The Department or the 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 Sections
					 50088,
					 50163, and
					 50185.
1.
						Amendment filed 12-30-81 as an emergency; effective upon filing (Register 82,
						No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days
						or emergency language will be repealed on 4-29-82.
2. Certificate of
						Compliance transmitted to OAL 4-23-82 and filed 5-12-82 (Register 82, No.
						20).
3. New subsection (b) and subsection relettering, and amendment
						of newly designated subsection (c) and NOTE filed 4-13-93; operative 5-13-93
						(Register 93, No. 16).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  11004,
						  14009,
						  14014,
						  14016.4
						  and
						  14024,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50789 - Failure to Repay. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1.
						Repealer filed 12-30-81 as an emergency effective upon filing (Register 82, No.
						1). A Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 4-29-82.
2. Certificate of
						Compliance transmitted to OAL 4-23-82 and filed 5-12-82 (Register 82, No.
						20).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code; Section
						  133.5, Chapter 102, Statutes of
						  1981. Reference: Sections
						  11004,
						  14009
						  and
						  14016.4,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50791 - Medi-Cal Overpayments Fraud - AFDC Cash Grant

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) When an AFDC overpayment occurs, the
					 county department shall:
(1) Investigate any
					 potential Medi-Cal fraud which is incidental to AFDC cash grant fraud and take
					 appropriate action.
(2) Determine
					 whether there was ineligibility for Medi-Cal as an AFDC recipient. If so, the
					 county shall determine whether:
(A) Medi-Cal
					 eligibility existed under any other program.
(B) There was a potential Medi-Cal
					 overpayment.
(C) Report potential
					 Medi-Cal overpayments to the county unit designated to collect Medi-Cal
					 overpayments caused by AFDC recipients.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 16 - OVERPAYMENTS, FRAUD AND IMPROPER UTILIZATION › Section 50793 - Utilization Restrictions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 A beneficiary who has been determined by the Department to be misusing or
					 abusing Medi-Cal benefits by obtaining drugs or other services at a frequency
					 or amount not medically necessary may be subjected to one or more of the
					 following forms of utilization restriction:
(1) Prior authorization for all Medi-Cal
					 services.
(2) Prior authorization
					 for specific Medi-Cal services.
(3)
					 Restriction to utilization of a specific, beneficiary- or Department-selected
					 pharmacy.
(4) Restriction to a
					 specific, beneficiary- or Department-selected primary provider of medical
					 services.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 17 - DIALYSIS MEDI-CAL PROGRAM › Section 50801 - Medi-Cal Special Treatment Programs - General

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
For the purposes of determining eligibility for Medi-Cal
						Special Treatment Programs, the regulations in this article shall supersede any
						conflicting regulations in this chapter.
1.
						Amendment filed 5-16-80 as an emergency; effective upon filing (Register 80,
						No. 20). A Certificate of Compliance must be transmitted to OAH within 120 days
						or emergency language will be repealed on 9-14-80.
2. Certificate of
						Compliance filed 8-22-80 (Register 80, No. 34).
3. Amendment filed
						3-25-81 as an emergency; effective upon filing (Register 81, No. 13). A
						Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 7-23-81.
4. Order of Repeal
						of 3-25-81 emergency order filed 4-3-81 by OAL pursuant to Government Code
						Section
						11349.6
						(Register 81, No. 14).
5. Amendment filed 7-19-82; effective
						thirtieth day thereafter (Register 82, No. 30).
6. Editorial
						correction of NOTE filed 11-10-83 (Register 83, No.
						46).
Note: Authority cited: Sections
						  10725
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14141,
						  14142,
						  14143,
						  14144
						  and
						  14144.5,
						  Welfare and Institutions Code.
California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 2 - Determination of Medi-Cal Eligibility and Share of Cost › Article 17 - DIALYSIS MEDI-CAL PROGRAM › Section 50803 - Medi-Cal Special Treatment Programs Beneficiary

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Medi-Cal Special Treatment Programs
					 beneficiary means a person who is either a Medi-Cal Special Treatment
					 Programs--Only beneficiary or a Medi-Cal Special Treatment Programs--Supplement
					 beneficiary.
(1) Medi-Cal Special Treatment
					 Programs--Only beneficiary means a person who has been determined eligible for
					 Medi-Cal Special Treatment Programs--Only coverage in accordance with Section
					 50817(b).
(2) Medi-Cal Special Treatment
					 Programs--Supplement beneficiary means a person who is a Medi-Cal Medically
					 Needy or Medically Indigent beneficiary and who has been determined eligible
					 for the Medi-Cal Special Treatment Programs--Supplement coverage in accordance
					 with Section
					 50817(c).