California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 8 - CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE › Article 6 - ISSUER REPORTING REQUIREMENTS AND AUDIT INFORMATION › Section 58082 - Auditing and Correcting Deficiencies in Issuer Record Keeping

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Within one (1)
					 year of the first date that any Policy or Certificate holder of a particular
					 Issuer's Policy or Certificate has met the criteria for Benefit Eligibility,
					 and as often as the Department of Health Services deems necessary thereafter,
					 the Department of Health Services, or its appointed designee, shall conduct a
					 systems audit of that company's records. The Issuer shall be responsible for
					 advising the Department of Health Services when this one (1) year period has
					 begun. The Department of Health Services, or its appointed designee, shall
					 inform each Issuer of inaccuracies and other potential problems discovered in
					 its systems audits, and the Issuer shall correct any problems in its methods of
					 operation.
(b) The Department of
					 Health Services shall periodically reconcile a sample of individual
					 applications for Medi-Cal of persons who have submitted documentation for
					 qualification for the Medi-Cal Property Exemption with the reports submitted by
					 Issuers. The Department shall have the final decision concerning sample sizes
					 and other auditing methods. The Department of Health Services shall promptly
					 advise Issuers of any problems discovered, and the Issuer shall correct any
					 problems in its method of operation. The Department of Health Services shall
					 also notify the Issuer of any obligations described in this Chapter to hold
					 clients harmless.
(c) The
					 Department of Health Servicers may enter into voluntary arrangements with
					 Issuers of Partnership Long-Term Care Insurance Policies and Certificates under
					 which the Department of Heath Services would issue binding determinations as to
					 whether or not services qualify for a Medi-Cal Property Exemption. Requests for
					 information and advice from Policy or Certificate holders shall be directed
					 through their Issuer or Care Management Provider Agency. When the procedures in
					 this section are followed, the written determinations of the Department of
					 Health Services concerning whether services qualify for a Medi-Cal Property
					 Exemption shall be binding upon the Department of Health Services in all
					 subsequent actions, and the Department of Health Services shall not make any
					 assertion contradicting these determinations in any action arising in this
					 subsection:
(1) All requests for
					 determinations as to whether or not services qualify for a Medi-Cal Property
					 Exemption shall be submitted to the California Partnership for Long-Term Care
					 in writing. These requests may include, but are not limited to, requests for
					 determinations in the following areas:
(A)
					 whether Benefit Eligibility has occurred and has been adequately
					 documented;
(B) whether a revision
					 of a Plan of Care is required;
(C)
					 whether a service or services are in accord with the Plan of Care;
(D) whether a service is of such a nature as
					 to qualify for a Medi-Cal Property Exemption; and
(E) whether the applicable amount is the
					 amount paid by the Issuer or the amount charged for the
					 service.