Beneficiary Reimbursement Process
Optometry Services
Frequently Asked Questions
Background
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On July 1, 2009, the Department of Health Care Services (DHCS) excluded several optional benefits, including optometry services, from coverage for adult beneficiaries under the Medi-Cal program pursuant to Assembly Bill X3 5 (Chapter 20, Statutes of 2009-10, Third Extraordinary Session).
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Effective July 26, 2010, DHCS reinstated optometry services as a Medi-Cal covered benefit for adult beneficiaries 21 years of age or older under the Medi-Cal program. Optometry services now payable include routine eye examinations, office visits, and certain diagnostic, ancillary and supplemental procedures used for the evaluation of the visual system. Services relating to the supply, replacement or repair of eyeglasses and other eye appliances will remain non-covered benefits for adult Medi-Cal beneficiaries.
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As part of the reinstatement process, State law requires that providers reimburse eligible Medi-Cal beneficiaries for their paid out-of-pocket expense of covered services that should have been billed to and paid for by Medi-Cal. If a Medi-Cal beneficiary requests reimbursement for optometry services provided July 1, 2009 through July 25, 2010, that would have been a Medi-Cal covered service but for the exclusion, providers must reimburse the beneficiary in full and bill Medi-Cal for those covered services.
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Frequently Asked Questions
What is the statutory authority that mandates the beneficiary reimbursement process (BRP)?
Are providers required to reimburse every Medi-Cal beneficiary who paid out-of-pocket expenses for optometry services from July 1, 2009, through July 25, 2010, or only those that request reimbursement?
Do I have to identify and contact patients who paid out-of-pocket for optometry services from July 1, 2009 through July 25, 2010?
For dates of service over one year, how can providers determine the beneficiary’s Medi-Cal eligibility?
Which optometry services are providers required to reimburse Medi-Cal beneficiaries if requested?
What happens if a provider does not comply with the BRP?
Can providers also expect to receive reimbursement from the Medi-Cal Managed Care Plans (e.g., those administered by Vision Service Plan (VSP), March Vision, etc.) or does the BRP apply only to fee-for-service Medi-Cal program only?
Does the BRP impact Medi-Cal/Medicare crossover claims?
If the Medi-Cal/Medicare patient paid only for a refraction, will that fee need to be reimbursed to the patient?
Does the status of the state budget impact the payment of BRP claims?
Who should providers contact for additional questions regarding the Medi-Cal BRP?
Question 1: What is the statutory authority that mandates the beneficiary reimbursement process?
Answer: The Beneficiary Reimbursement Process (BRP) is required pursuant to Welfare and Institutions Code Section 14019.3. In addition, the BRP is mandated by court order issued on November 17, 2006, in the litigation entitled, Conlan vs. Shewry.
For detailed information regarding the Medi-Cal BRP, including the criteria required to establish a valid claim for beneficiary reimbursement, please contact the Beneficiary Services Center (BSC) at (916) 403-2007, or visit the Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) section in Part 2 of the Medi-Cal Vision Care manual and the Beneficiary Reimbursement Process page of the DHCS website at the following link: http://www.dhcs.ca.gov/services/medi-cal/Pages/Medi-Cal_Conlan.aspx
Question 2: What steps should providers follow to ensure the BRP is handled correctly?
Answer: If a Medi-Cal beneficiary request reimbursement for paid out-of-pocket expenses from July 1, 2009 through July 25, 2010 for optometry services now payable, providers should follow the following steps:
1. Verify that the date of service is from July 1, 2009, through July 25, 2010. (Refer to Question 8 for additional information).
2. Verify that the beneficiary was eligible for Medi-Cal on the date of service. The BRP is not available for non-eligible Medi-Cal beneficiaries.
3. Verify that the beneficiary paid an out-of-pocket expense that is for optometry services now payable (excluding eyeglasses and other eye appliances) on July 26, 2010.
4. If first steps 1-3 are met, reimburse the beneficiary in full for the paid out-of-pocket expense(s). Complete this step before moving to step 5.
5. Bill Medi-Cal for the same service reimbursed to the patient.
6. If the beneficiary belongs to a Medi-Cal Managed Care Plan, contact the plan directly for assistance. The plans have been notified by DHCS of the BRP.
Question 3: Will BRP claims for these reinstated optometry services with dates of service over one year be denied for timeliness?
Answer: No. The Department of Health Care Services (DHCS) will override claims submission timeliness for these reinstated optometry services if the claim for payment is submitted on or before July 25, 2011. Provider claims submitted after July 25, 2011 will be processed under normal claims submission criteria. In some cases where a request for reimbursement has been received from the beneficiary, the Department may provide a separate notice to the provider that waives timeliness for an additional period of time (BRP Letter # 8). Claims can be submitted to Medi-Cal Fiscal Intermediary, P.O. Box 15700, Sacramento, CA 95852-1700.
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Question 4: How long do Medi-Cal beneficiaries have to request reimbursement?
Answer: Medi-Cal beneficiaries have until February 1, 2011 (or up to 1 year from the date of service, or 90 days from the issuance of their BIC, whichever is longer), to submit a request for reimbursement to the Department. After this date, DHCS will no longer accept nor process any beneficiary BRP claims.
Question 5: When will Medi-Cal beneficiaries be notified of the BRP and how can providers obtain a copy of the letter?
Answer: Medi-Cal beneficiaries will be notified of the optometry services reinstatement and beneficiary reimbursement process through the Jackson v. Rank quarterly mailings in early October 2010. A copy of the beneficiary notice in twelve threshold languages is available on the DHCS Web site at the following address: http://www.dhcs.ca.gov/services/Pages/OptometryServicesReinstatementBeneficiaryNotice.aspx
Question 6: Are providers required to reimburse every Medi-Cal beneficiary who paid out-of-pocket expenses for optometry services from July 1, 2009, through July 25, 2010, or only those that request reimbursement?
Answer: Providers are only expected to reimburse those beneficiaries who present to the provider’s office and are requesting reimbursement for their paid out of pocket expenses. The provider may then bill Medi-Cal for the same service.
Question 7: Do I have to identify and contact patients who paid out-of-pocket for optometry services from July 1, 2009 through July 25, 2010?
Answer: No, it is the responsibility of the eligible beneficiaries to contact providers to seek reimbursement for paid out-of-pocket expenses for services that would have been covered by Medi-Cal.
Question 8: For dates of service over one year, how can providers determine the beneficiary’s Medi-Cal eligibility?
Answer: For dates of service over one year, providers can contact the Beneficiary Service Center (BSC) for assistance in verifying the beneficiary’s Medi-Cal eligibility. The BSC was established to work with both providers and beneficiaries to process Beneficiary Reimbursement claims. The BSC address and telephone number are as follows:
Beneficiary Service Center
P.O. Box 138008
Sacramento, CA 95813-8008
(916) 403-2007
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Question 9: Which optometry services are providers required to reimburse Medi-Cal beneficiaries if requested?
Answer: Under the July 26, 2010, reinstatement by the Department, providers, if requested, are only required to reimburse Medi-Cal beneficiaries who paid out-of-pocket expenses from July 1, 2009, through July 25, 2010 for optometry services now payable. These covered services include routine eye examinations, refraction test, office visits, and certain diagnostic, ancillary and supplemental procedures used for the evaluation of the visual system. Eyeglasses and other eye appliances remain non-covered benefits for adult Medi-Cal beneficiaries, and are not reimbursable. For a list of optometry services now payable, please refer to the Rates: Maximum Reimbursement for Optometry Services in the Medi-Cal Vision Care Manual which can be accessed at the following link: http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/ratesmaxoptom_v00.doc
Note: Pursuant to Welfare and Institutions Code Section 14019.3, upon presentation of proof of eligibility, a beneficiary or any person on behalf of a beneficiary who has paid for medically necessary health care services, otherwise covered by the Medi-Cal program, received by the beneficiary is entitled to the return from a provider of any part of the (out-of-pocket) payment (that was not required to meet co-payments, share of cost or other cost-sharing requirement(s)). That provider may upon presentation of the Medi-Cal card or other proof of eligibility, submit a Medi-Cal claim for reimbursement, subject to the rules and regulations of the Medi-Cal program.
Question 10: What happens if a provider does not comply with the BRP?
Answer: In accordance with the court order issued on November 17, 2006, in the litigation entitled, Conlan vs. Shewry, providers that do not comply with a valid request for beneficiary reimbursement are subject to a recoupment action by the Department of all monies paid to the provider by the beneficiary for Medi-Cal covered services, as appropriate.
Question 11: Can providers also expect to receive reimbursement from the Medi-Cal Managed Care Plans (e.g., those administered by Vision Service Plan (VSP), March Vision, etc.) or does the BRP apply only to fee-for-service Medi-Cal program only?
Answer: The BRP process impacts both the Medi-Cal fee-for-service and the Managed Care Program. For beneficiaries in Managed Care Plans administered by VSP, all BRP requests from the beneficiary or the provider to VSP will be referred back to the plan to be handled on a case by case basis. As the plans administer the benefits differently, providers are encouraged to contact all other plans directly regarding the BRP should a beneficiary request reimbursement.
Question 12: Does the BRP impact Medi-Cal/Medicare crossover claims?
Answer: No, Medi-Cal/Medicare crossover claims were not impacted by the Optional Benefits Elimination on July 1, 2009. Claims for beneficiaries denied by Medicare because of the deductible amount should have crossed over automatically and were paid by Medi-Cal.
Question 13: If the Medi-Cal/Medicare patient paid only for a refraction, will that fee need to be reimbursed to the patient?
Answer: If the beneficiary paid the out-of-pocket expense from July 1, 2009, through July 25, 2010, for the refraction and requests reimbursement, the provider must reimburse the beneficiary and bill the refraction service to Medi-Cal for payment.
Question 14: Does the status of the state budget impact the payment of BRP claims?
Answer: Claims for Medi-Cal services rendered to beneficiaries from optometrists will continue to receive payment regardless of the status of the state budget. See bulletin article: http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_11797.asp
Question 15: Who should providers contact for additional questions regarding the Medi-Cal BRP?
Answer: For additional questions on the BRP, providers can contact the Beneficiary Service Center at (916) 403-2007 or Dr. Donny Shiu, Medi-Cal Vision Care Program Consultant, at (916) 552-9500 or e-mail: vision@dhcs.ca.gov.
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