Other Health Care Regulation


The State has two methods for utilizing Other Health Care (OHC) information on Medi-Cal beneficiaries.  These are the:


·        Post Recovery; and

·        Cost Avoidance methods. 


Under Post Recovery, Medi-Cal pays the provider’s claim first and then seeks reimbursement from the other health care coverage. 


Under Cost Avoidance, the provider must bill the other health care coverage prior to billing Medi-Cal.  Claims for beneficiaries with cost avoidance OHC will not be paid by Medi-Cal until the OHC has first been billed.       



Exemptions to OHC



The following types of medical coverage are excluded from the OHC coding requirements and from the completion of Form DHS 6155:


    Medicare, with the exception of Medicare HMO.

·       Most Veterans’ Administration (VA) benefits except CHAMPUS.


·       Accident, automobile, burial and life insurance benefits.


·       Disability and Worker’s Compensation benefits.


·       Coverage under Health Care Plans (HCPs), which has contracted with the CDHS to provide Medi-Cal services to eligible beneficiaries.  CalWORKs recipients must choose between a contracted HCP and regular Medi-Cal coverage during the Health Care Options (HCO) presentation at Orientation.  


·       Coverage Considered Unavailable.



OHC Unavailable

In the following situations, coverage will be considered unavailable:


·        The parent or guardian refuses to provide the necessary information due to “good cause”.  Good cause exists when cooperation in securing medical support and payments, establishing paternity, and obtaining or providing information concerning liable or potentially liable third parties from the absent parent can be reasonably anticipated to result in serious physical or emotional harm to the child for whom support is being sought or to the parent or caretaker with whom the child is living;


·       The absent parent cannot be located; or


·       Any coverage to which a child may be entitled when the child is applying for minor consent services.  The obligation to utilize OHC before Medi-Cal is modified in those situations where utilization of OHC would violate a person’s right to confidentiality regarding his/her Medi-Cal status, such as minor consent.    



Use of Cost Avoidance/
Post Recovery Codes

The HSS will use the cost avoidance OHC code when the applicant/beneficiary reports OHC except as indicated above when OHC is unavailable.


When the HSS determines that use of a cost avoidance OHC code is appropriate, the effective date of the cost avoidance code is determined as follows:


New Applicant


       The effective date of the cost avoidance OHC codes for new applicants will be the first month of eligibility.




The effective date of the cost avoidance OHC codes for re-determinations will be the future month.  When the cost avoidance coverage was available prior to the re-determination but not previously reported by the beneficiary, the beneficiary must complete Form DHS 6155.  The HSS will notate “CA/Retro” in the upper right hand corner of Form DHS 6155.



Outside Service Area

When a client reports that he/she lives outside the service area of the health plan under which he/she has coverage, or must travel more than 60 miles or 60 minutes to receive care from the plan, an OHC of “other” must be entered in the H/C code field located in the Health Care Information tab/Collect Individual Attributes window. .  This coding will allow the state to recover claims paid for emergency service by Medi-Cal individuals residing out of their plan’s service area.


A Form DHS 6155 also must be completed and sent to the CDHS for a person who has other health coverage but resides outside the health plan’s service area, or must travel more than 60 miles or 60 minutes to receive care.  In this case, a statement “Outside Health Plan Area” must be noted in question number 1, next to the insurance carrier’s name.



Medical Support Regulation

The Medical Support Program collects information from absent parent(s) about health insurance coverage available to a dependent child.  This section provides staff with information and procedures used in the Medical Support Program, including HSS responsibilities.


State law requires non-custodial/absent parents to provide information about medical insurance coverage in child support actions taken by the Local Child Support Agency (LCSA).  Failure to cooperate with LCSA will result in the CalWORKs recipient being ineligible to Medi-Cal benefits.



Non-Cooperation with LCSA

When recipient is non-cooperative with LCSA) the assistance unit’s (AU) case will be penalized a 25% grant reduction as well as the recipient being ineligible for Medi-Cal benefits. To notify the Medi-Cal Eligibility Data System (MEDS) of the recipient’s ineligibility to Medi-Cal, the HSS must complete a 14-28 HHSA with one of the following restriction codes:


·      970 or 971 (The 1 in the 971 indicates a County confidential case).


Future cooperation with the LCSA will result in the restoration of Medi-Cal benefits. To remove a restriction code, the HSS must complete a 14-28 HHSA with one of the following codes:


·      970 (use 000) or 971(use 000 to remove the restriction then 001) 


Note Exceptions:  Pregnant women are exempt from medical support enforcement until 60 days postpartum and children cannot be denied or terminated from Medi-Cal due to a custodial parent’s refusal to cooperate with the LCSA.  



OHC located by DCSS

The LCSA will obtain form DHS 6110 in all child support actions where children are receiving Medi-Cal and/or CalWORKs benefits.  Form DHS 6110 is used by the LCSA to gather information to identify the Non-Custodial/Absent Parent’s Other Health Care Coverage (OHC)


The form DHS 6143, Cover Letter, is used by the State as a cover letter to the form DHS 6110.  It identifies any actions to be taken by the HSS on the beneficiary’s case, when OHC is discovered by the LCSA


 When the HSS receives the form DHS 6110 and DHS 6143 Cover Letter, they must do the following:


·   File the Notification of Health Insurance Coverage Forms DHS 6110, and DHS 6143 in he case folder; and


·   Enter the appropriate OHC code located in the Health Care Information tab/Collect Individual Attributes window.   


Note:  Once the HSS makes the OHC code change, they will receive a MEDS alert that the code has changed.  If no action is taken, the HSS will receive an alert that MEDS does not match and the HSS must make the OHC code change on to match MEDS.


The HSS will instruct the beneficiary that the OHC insurance must now be used prior to using Medi-Cal.  The HSS may contact the client either by phone or letter and will narrate the action in the case comments.