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Medi-Cal Out-of-Pocket Expense Reimbursement (Conlan)

As the result of a court order issued on November 17, 2006, in the litigation entitled, Conlan v. Shewry, Medi-Cal may be able to reimburse you for covered medical and/or dental expenses you paid.  For your information, here is a summary of the court ordered Revised Plan for Beneficiary Reimbursement and accompanying Beneficiary Notice.

           

You may be able to receive a reimbursement if:

  1. You received a Medi-Cal covered service on a date that you were eligible for Medi-Cal.  The three periods of eligibility that are included are the following:
    • RETRO: The 3-month period prior to the month you applied for the Medi-Cal program.  This period of eligibility is covered only when you have requested and it has been approved from your county representative or directly from Medi-Cal that specific dates and services before you applied for Medi-Cal be included in your period of eligibility.
    • EVALUATION: From the date you applied for the Medi-Cal program until the date your Medi-Cal card was issued.  For services and products received on or after February 2, 2006, the provider must have been a Medi-Cal provider on the date the service was provided.
    • POST APPROVAL: After your Medi-Cal card was issued (includes excess co-payment and excess share of cost charges).  The provider must have been a Medi-Cal provider on the date the service was provided.
  2. You paid for your medical or dental service; or another person paid for your medical or dental service on your behalf.
  3. The medical or dental service was provided on or after June 27, 1997.
  4. After you received your Medi-Cal card, you contacted your provider and showed your provider your Medi-Cal card and the provider would not reimburse your money. 

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Important dates:

  • For services received from June 27, 1997, through November 16, 2006, you must submit (mail) your claim by November 16, 2007, or within 90 days after issuance of the Medi-Cal card, which ever is longer.  Good cause exception.  On September 5, 2008, the Court ordered the following amendment be made to the Beneficiary Reimbursement Plan: 
  • Respondents (Department of Health Care Services) shall allow claimants that allege “good cause” for late filing “old claims” to prove such an allegation, and if successful, receive a determination on the merits of their claims.  “Old claims” are those that arise from paid out of pocket expenses for covered services for dates of service during the period June 27, 1997 through November 16, 2006.  The determination of “good cause” shall be made based upon that standard set forth in Welfare & Institutions Code Section 10951(b)(2), as set forth here:

     [G]ood Cause means a substantial and compelling reason beyond the party’s control, considering the length of delay, the diligence of the party making the request, and potential prejudice to the other party.  The inability of a person to understand an adequate and language compliant notice, in and of itself, shall not constitute good cause.”

    If you missed the filing date for an old claim and believe your late filing was due to good cause as described above, you must inform the Department of Health Care Services (DHCS) of the good cause for the late filing in order for DHCS to administratively review that allegation and make a decision as to whether good cause exists to excuse the untimely filing.
  • For services received on or after November 16, 2006, you must submit (mail) your claim within one year of receipt of services or within 90 days after issuance of the Medi-Cal card, whichever is longer.
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 If you submit a complete and valid claim, there are three (3) ways that reimbursement can be issued:

  1. Voluntary Provider Reimbursement: If the provider voluntarily agrees to reimburse the entire payment you made for a service that should have been covered by Medi-Cal.  In most cases this payment of the entire expense you paid for that service will come to you directly from the provider.
  2. Involuntary Provider Reimbursement/Recoupment: If the provider does not voluntarily agree to reimburse the entire payment you made for a service that should have been covered by Medi-Cal.  In this case, the payment of the entire expense you paid for that service will be recovered/recouped from the provider by Medi-Cal.  The reimbursement for the full amount of the expense you paid for the service will be issued directly to you from Medi-Cal.
  3. Medi-Cal Reimbursement up to the Medi-Cal Rate: If Medi-Cal is unable to recover/recoup the payment from the provider.  (For example: the provider no longer exists; was not a Medi-Cal provider at the time of the service; is no longer a Medi-Cal provider with funds to recover, or is currently a Medi-Cal provider but does not bill for enough services to provide sufficient funds for Medi-Cal to recover/recoup the paid expense.)  In this case, the reimbursement payment will be issued directly to you from Medi-Cal. The reimbursement will be up to the Medi-Cal allowed rate for the service, but never more than the expense of the payment you made to the provider.  In most cases, the Medi-Cal rate will be less than the payment made to the provider.  As a result, the reimbursement payment issued to you by Medi-Cal will be less than the payment you made to the provider.

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For more information or to file a claim, please call or write to Medi-Cal at:

California Department of Health Care Services / Beneficiary Services Center

P.O. Box 13008

Sacramento, CA 95813-9998

Phone: (916) 403-2007   TDD: (916) 635-6491

 

Your Rights:  

You have the right to request a state hearing to review a Medi-Cal decision or action regarding your request for a Beneficiary Reimbursement.  You must request a state hearing within 90 days of the date on the Notice of Action that informs you of the decision or action that was mailed to you by the department reviewing your request.  Please follow the instructions provided in the Notice of Action to request a state hearing or call the California Department of Social Services’ State Hearings Division at 1-800-952-5253.  For TDD service, call 1-800-952-8349.  Written requests must be mailed to:

 

State Hearings Division

California Department of Social Services

P.O. Box 944243, Mail Station 19-99

Sacramento, CA 94244-2430

 

State regulations including those covering state hearings (California Code of Regulations, Title 22, Section 50951) are available at your local county welfare office or on the Internet at www.calregs.com.     

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BENEFICIARY NOTICE:

November 2006 Beneficiary Notice for Reimbursement of Out of Pocket Expenses.

(English and Spanish)   

Who is eligible, what services are covered, what time periods are covered, when can a claim be filed and how to get more information about submitting a claim for reimbursement.

 

Request for a Beneficiary Notice in Other Languages  

Instructions on how to obtain a Beneficiary Notice for Reimbursement of Out of Pocket Expenses in Armenian, Chinese, Farsi, Hmong, Khmer, Korean, Lao, Russian and Vietnamese.

 

REVISED PLAN FOR BENEFICIARY REIMBURSEMENT:

Court Ordered Plan / Revised Plan for Beneficiary Reimbursement   

The detailed Revised Plan for reimbursing eligible Medi-Cal participants for their out of pocket expenses for covered medical or dental services.

 

November 17, 2006 Conlan v. Shewry Court Order      

The court order approving implementation of the Revised Plan for Beneficiary Reimbursement.

 

Last modified on: 10/28/2008 8:14 AM