A. FORM DHS 6155 – HEALTH INSURANCE QUESTIONNAIRE

 

44-400 Regulation

 

Applicants and/or beneficiaries are required to report and use any Other Health Care Coverage (OHC) to which they are entitled.  The OHC information is completed on the Form DHS 6155 and sent to the California Department of Health Services (CDHS). 

 

 

Other Health Care Coverage

Other health care coverage is any benefit for health related services or entitlements for which a Medi-Cal beneficiary is eligible under private, group, or governmental insurance programs.

 

The following list contains, but is not limited to, a few of the various policies that provide other health care coverage:

 

·        Dental - Policies that provide dental services only.

 

·        Health - Policies that cover hospital expenses, surgical expenses, routine medical expenses, or major medical.

 

·        Hospital - Polices that cover expenses incurred during

hospitalization.

 

·        Prescription – Policies that cover prescribed drugs only.

 

·        Vision - Policies that cover vision-related expenses only

 

·        Student Health - Health insurance offered through an educational   institution for enrolled students.

 

 

 

Applicant/

Beneficiary Responsibility

 

 

Applicants/beneficiaries for Medi-Cal are required to report OHC coverage.  This requirement applies at application, reapplication or re-determination and within 10 calendar days from the date of changes in their OHC.

 

Acceptable verification of OHC coverage includes but is not limited to:

 

·       Insurance policies, which specifically name the applicant.

 

·       Health benefit identification cards or letters from health care benefit providers.

 

 

Form DHS

6155

County Responsibility

 

The Human Services Specialist (HSS) is responsible for identifying any OHC available to the client, providing general OHC information and ensuring that the Form DHS 6155 is completed, reviewed and sent to the CDHS.

 

The HSS must review information provided at application to determine if there is a positive response to the question(s) about having any private health insurance and if a Form DHS 6155 should be completed.

 

Note:  Although the HSS is to make it clear that Form DHS 6155 is required, there is no penalty for failure to do so.  Aid is not to be denied or discontinued for failure to provide information on other health care coverage. .

 

 

Processing Form DHS 6155

The HSS must check the following items prior to the submission of the Form DHS 6155 to the State:

        

·           Check the entries for completeness...  All information requested must be complete. (The client’s signature/date is not required for CDHS purposes).  

 

·           Only persons covered by the OHC must be listed on the Form DHS 6155.  If the client lists a member of the AU who is not covered, that persons name is to be lined through.

 

·           The 14-digit State Medi-Cal identifier must be completed.  The format for the 14-digit code is identified as:

 

1. County Code - San Diego County code is 37

2. Aid Code - 30, 35, etc.

3. Case Number - 7 digit county case number

4. FBU For CalWORKs, the FBU would be 0.

5. Person Number.

 

·        The County Use section of the form must be completed.

 

·           If the client indicates PHP/HMO coverage or answers, “yes” to question #2. Code the case for PHP coverage located in the Health Care Information tab/ Collect Individual Attributes window.

        

 Note:        When the Person number changes or Aid Code changes by 10’s (i.e. 10 to 20, 30 to 80, etc.) for a beneficiary covered by other health care and eligible to Medi-Cal, the Health Insurance Unit of the California Department of Health Services must be notified.   HSSs must photocopy the case copy of the Form DHS 6155 and make any changes in Red on the copy and forward it to the California Department of Health Services (CDHS).  A copy of the updated Form DHS 6155 must also be filed in the case file.

 

One copy of the completed Form DHS 6155 is to be filed under the Medi-Cal tab in the financial folder.  The original Form DHS 6155 is to be forwarded to: 

 

                             California Department of Health Services

                 Health Insurance Unit

                 Recovery Branch

                 P.O. Box 1287

                 Sacramento, CA  95812-1287

 

 

Form DHS 6155 Returned by the State

Occasionally the State will return the Form DHS 6155 to the county.  The returned form(s) is sent to the last HSS of record.  The most common reasons for returning the form(s) are:

 

·       The 14-digit Medi-Cal identifier is missing or inaccurate.

 

·       There is insufficient information regarding the insurance policy and or the policyholder.

 

When the Form DHS 6155 has been returned, the HSS must take the following actions:

 

·       If returned for a missing or incorrect Medi-Cal identifier, the HSS must add or correct the number.

 

·       If returned for insufficient information on the insurance or policyholder, the HSS must contact the client to obtain the information.  If the information is not available, the HSS must note this on the Form DHS 6155 and return to the State Recovery Branch. 

 

 

Beneficiary No Longer has OHC Coverage

·       When a beneficiary informs his/her HSS that his/her OHC has terminated, the HSS must verify termination of the OHC.  Acceptable verification is but not limited to:

 

o       A payroll check stub showing the deductions for private health insurance has ceased.

 

o       A termination letter from the insurance carrier and/or employer showing the date the policy terminated.

 

o       A sworn statement signed by the client stating that he/she no longer has OHC.  The sworn statement must also include the date the policy was terminated if that information is known.

 

·                    When the client informs his/her HSS that his/her OHC has terminated, the HSS must take the following actions to remove the OHC code:

 

 

Step

Action

1

Update the case copy of the Form DHS 6155 showing the OHC policy termination date (in red).

2

Attach a copy of the OHC termination verification to the updated Form DHS 6155 and mail to the CDHS

3

Retain copies of the updated Form DHS 6155 and OHC termination for the case record

4

If the termination letter indicates that continuation of medical benefits are available under the Consolidated Omnibus Budget Reconciliation Act (COBRA) law, and the beneficiary has a high cost medical condition, the HSS should complete a Form DHS 6155 and send it to:

 

          California Department of Health Services

          Health Insurance Premium Payment Unit

          P.O. Box 1287

          Sacramento, CA 95812-1287 

 

5

Change the OHC code to “N” located in the Health Care Information tab/Collect Individual Attributes window.

 

Incorrect OHC Code/

Immediate Need

 

When a Medi-Cal beneficiary indicates that an incorrect OHC code is interfering with obtaining needed medical services, the following procedures will be used:                

 

 

 

Step

Action

1

Ask the beneficiary to provide one of the acceptable verifications listed above, indicating termination of the OHC.

2

Complete a Form DHS 6155

3

Fax the verification and Form DHS 6155 to the CDHS, OHC Department, at (916) 324-3065.  Mark urgent on the fax coversheet for expedited processing.  After sending the fax, mail a copy of the Form DHS to the California Department of Health Services.

4

Submit a request for an on-line transaction to remove the OHC code, other than a “9” (Healthy Families), for services needed that day.

5

Change the OHC code to “N” located in the Health Care Information tab/Collect Individual Attributes window.

 

If the beneficiary informs the HSS that the OHC has ended and the beneficiary now has other medical coverage, the HSS will enter the OHC code for the new coverage, complete a new Form DHS 6155, and submit to the CDHS.