Article 15 Section 1 – Other Health Coverage (OHC)


Table of Contents



MPG Cite

OHC General Information


Responsibility for Reporting


OHC Reporting, Terminations, Changes, and Modifications


Medicare HMO Premium Payments


Health Insurance Premium Payment (HIPP)


Employer Group Health Plan (EGHP)








Desk Aid

·   Desk Aid 41 How To Access And Complete Form DHCS 6172 On-Line

·   Desk Aid 42 How To Add or Remove OHC

·   Desk Aid 43 Samples Of When Not To Report OHC



15.01.01 Introduction


Billing and Payment

Medi-Cal applicants/beneficiaries are required to report and use any OHC to which they are entitled. The Medi-Cal program is designed by law as the payer of last resort for health care services/benefits. Health insurance carriers are obligated to reimburse the Medi-Cal program for the cost of any health care services received by a beneficiary when they are covered under the terms of an insurance policy. Money collected by Medi-Cal from insurance carriers is used to pay for health care benefits.


MPG LTR 325 (11/95)




Cost Avoidance vs. Post Recovery

The state has two methods for utilizing OHC information for Medi-Cal beneficiaries:



Billing Process

Cost Avoidance

The service provider must bill the OHC provider prior to billing Medi-Cal. NOTE: Claims for beneficiaries with cost avoidance coverage will not be paid by Medi-Cal without an Explanation of Benefits (EOB) from the OHC provider.

Post Recovery

Medi-Cal bills the OHC provider after paying the service provider.


DHCS places the OHC method information on MEDS as follows:


Code Type


Cost Avoidance

From information matched with health insurance companies.

Post Recovery

From information received through CalWIN.


ACWDL 94-82


ACWDL 96-26



Effective Dates of OHC Codes

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



Effective Date

New Application

First of the month of eligibility


Future month


MPG LTR 350 (03/96)







15.01.02 - Responsibility for Reporting


When to Report

Counties shall no longer add OHC records to MEDS except under the following conditions:


·   The applicant/beneficiary provides information that the OHC they have is not on the list of Current Trading Partners found at .

·   The applicant or beneficiary has OHC that is not found in MEDS and wants their OHC added to their record.


MPG LTR 796 (07/13)




When Not to Report OHC

Staff will not request an addition for OHC if the addition:

·   Endangers a beneficiary

·   Creates a barrier to care

·   Another government program provides OHC information


For samples of when not to report OHC, see Desk Aid 43.


MPG LTR 796 (07/13)




Documentation Required for OHC Changes

DHCS stores OHC data in the Health Insurance System (HIS) in MEDS. OHC codes are updated as follows: 


When ...

Then ...

active HIS record is available

MEDS automatically selects and displays the correct OHC code

no active HIS record is found

the system sets the MEDS OHC code to “N”


The following information will be needed to add or modify a HIS record:

·   Health plan name

·   Policy/medical record number

·   Member’s name


NOTE: This information may be obtained from the Medi-Cal applicant/beneficiary health plan policy or their health plan membership identification card.


MPG LTR 796 (07/13)

ACWDL 13-12


Repayment of Insurance Reimbursement

Applicant/beneficiaries must report and repay Medi-Cal for services received under Medi-Cal but reimbursed by their insurance provider.


The worker will instruct the applicant/beneficiary to forward reimbursement payments to:


            California Department of Health Care Services

            Third Party Liability Branch – MS 4719

            P.O. Box 997421

Sacramento, CA 95899-7421


Beneficiaries should endorse checks from insurance carriers as follows:


·   "For Deposit Only to Health Care Deposit Fund"

·   Name of Payee (party to whom the check is made payable)

·   Medi-Cal Identification Number of Beneficiary  (this may be a person different than the one who received the check)

·   Payment must be signed by either the payee or his/her agent


The applicant/beneficiary must enclose with the check the following information:


·   Date(s) of service

·   Provider's name

·   Daytime phone number where they can be reached


MPG LTR 762 (09/12)


I 12-05


15.01.03 OHC Coding, Terminations, Changes and Modifications



DHCS currently receives OHC data from several automated systems including:


·   over 20 health insurance carriers

·   Child Support

·   SSA

·   California Children Services


The data exchanges provide DHCS complete, accurate, and timely OHC information. Despite these data matches, counties are responsible for gathering and reporting additions, terminations, and changes.

NOTE: Additions must only be reported as outlined in MPG 15.01.02.A


MPG LTR 796 (07/13)




How to Report OHC

To add or remove OHC information, go to the OHC Processing center on the DHCS web site

 (  and complete the on-line form. See Desk Aid 42 – How To Add or Remove OHC for details on how to complete the on-line form.


NOTE: In situations where there is no internet access, staff may call the Medi-Cal intermediary at 1-800-541-5555 and, at the menu, press 2 as if you are a beneficiary. Be prepared to provide the same information specified in Desk Aid 42 – How To Add or Remove OHC.


MPG LTR 796 (07/13)





Required Verifications for Removal of OHC

To ensure that Medi-Cal is the payer of last resort, staff must verify that OHC terminated for the applicant or recipient whose OHC ended or who never had OHC, prior to removing the OHC code from MEDS.  The following is a list of acceptable verifications:


·   A payroll or pension check stub that shows deductions for private health insurance have ended.

·   An explanation of benefits from the insurance carrier and/or employer showing the date the policy terminated.

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

·   An affidavit see MPG 15.01.03.D for details.


NOTE: For SSI/SSP cases where there is no county case record, the county must view the verification prior to removing the OHC code from MEDS. Counties are not required to retain or send the verification to DHCS, but are required to assist the SSI/SSP beneficiary with their OHC issues.


MPG LTR 796 (07/13)





Acceptable Affidavits

An affidavit signed by the Medi-Cal applicant/beneficiary or their representative stating he/she no longer has, or never had OHC is acceptable. The affidavit must include the date the policy terminated, if known, or applicable. An affidavit may be used in any of the following situations:


·   an erroneous OHC code appears on a applicant/beneficiary’s Medi-Cal record

·   termination cannot otherwise be verified

·   the custodial parent or guardian cannot verify termination of an absent parent’s insurance

·   the applicant/beneficiary is claiming good cause as outlined in MPG 15.01.03.F


MPG LTR 796 (07/13)





Immediate Need Termination of OHC

To remove the OHC code for immediate need cases, staff may use a 14-28 HHSA and request a EW15 or EW55 transaction to update the OHC code for the current month to an “N”. This will only remove the OHC temporarily.


NOTE:  Do not use the EW15 or EW55 transaction to change OHC carrier information.


MPG LTR 796 (07/13)

ACWDL 13-12


Bypassing OHC for Good Cause

To bypass an OHC code an applicant/beneficiary must present “good cause”.  Below are examples of “good cause”:


·   Geographic barrier to care

·   Domestic violence situations

·   Beneficiary never had a plan with a carrier, yet HIS resets an OHC record that was removed during a previous month match


If “good cause” exists, staff must submit an OHC removal request as outlined in Desk Aid 42 – How To Add or Remove OHC and note the reason for “good cause” in the comment field.


The OHC Processing Center will set the OHC code so it is bypassed during the claim adjudication or put the beneficiary on a “no carrier match list” to prevent the next monthly OHC match from resetting the HIS record.


NOTE: In situations where the OHC removal for beneficiary that never had OHC coverage is not successful, it may be necessary to place the client on the “no carrier match list”. To place the beneficiary on the “no carrier match list”, follow the instructions on Desk Aid 42 – How To Add or Remove OHC and note “please place on the no carrier match list” in the comment field.


MPG LTR 796 (07/13)





15.01.04 Health Insurance Questionnaire


State Payment of Medicare HMOs Increase Premium Amounts

Effective January 1, 2001 DHCS began paying Medicare HMO premium increases not covered by Medicare for certain Medi-Cal beneficiaries enrolled in selected Medicare HMO Plans.  TPL determined that it would be more cost effective to have Medi-Cal pay the increased HMO premiums for eligible beneficiaries receiving both Medi-Cal and Medicare rather than have them disenroll and obtain their medical care on a fee-for-service basis.


 A Medicare beneficiary is eligible to have their increased Medicare HMO premium paid by the State if he/she meets the following criteria:

·   A full-scope Medi-Cal beneficiary, including both SOC and no SOC beneficiaries

·   Enrolled in one of the Medicare HMO plans affected by this change

·   Enrolled in a plan that includes both brand name and generic drugs


Note: Beneficiaries of QMB, SLMB or QI Programs, who are not receiving Medi-Cal, are not eligible to have the increased Medicare HMO premium paid by the State.


MPG LTR 449 (05/01)




Affected Health Plans

Beneficiaries who meet the eligibility criteria defined in MPG 15.01.04.A and belong to the following Medicare HMOs will have the increased premium paid by the State:

·   Blue Shield

·   Blue Cross

·   Health Net

·   Pacificare

·   Kaiser


MPG LTR 449 (05/01)

ACWDL 01-28



Listing of Eligible Medicare Beneficiaries

DHCS compiles a monthly listing identifying Medicare beneficiaries who will have their increased Medicare premium paid by the State. The listing, entitled “Medicare HMO Members - Premiums Paid by Medi-Cal,” is produced for each county in alphabetical order by the beneficiary’s last name. This report will be distributed to FRCs with granted Medi-Cal staff to confirm the premium payment when responding to beneficiary inquiries. Medicare beneficiaries with questions regarding their payment status may call the TPL toll free number, (866) 227-9863.


MPG LTR 449 (05/01)

ACWDL 01-28




Medicare HMO premiums will be treated as outlined in MPG 10.06.03.M and with the following additions:

·   The increased Medicare HMO premium will be treated as a health insurance deduction if the Medicare beneficiary provides proof that he/she is paying the premium and the individual is not identified on the listing.

·   The increased Medicare HMO premium will be removed as a health insurance deduction if information is received that the State is paying the premium.


All case action taken because of the increased Medicare HMO premium must be documented in case comments.


MPG LTR 449 (05/01)




15.01.05 Health Insurance Premium Payment (HIPP)



DHCS is authorized to pay health coverage premiums on behalf of medical beneficiaries through the Health Insurance Premium Payment (HIPP) Program whenever it is cost effective. Paying these premiums for high cost medical users results in reduced Medi-Cal costs.


Counties are responsible for identifying the existence or availability of private or group health insurance and assisting Medi-Cal beneficiaries in completing a DHCS 6172 on-line. Desk Aid 41 – “How to Access and Complete Form DHCS 6172 On-Line” provides step-by-step on-line completion instructions.


NOTE: Effective July 1, 2012, the DHCS paper form will no longer be available. Staff must go to the following website to complete form DHCS 6172: .


Information from the DHCS 6172 is used to help DHCS evaluate for HIPP.  DHCS will notify the county via e-mail if it will be paying the health care premiums. When the county is notified that the beneficiary has been accepted to the HIPP program, the worker will review the SOC and re-compute the budget it if necessary.


MPG LTR 796 (07/13)

ACWDL 90-23





HIPP Qualifying Factors

A person is potentially qualified for HIPP if:

·   There is current Medi-Cal eligibility.

·   There is a high cost medical condition for which the average Medi-Cal covered monthly cost is twice the amount of the monthly health insurance premium, or the medical condition is one of those listed in Appendix E.

·   There is a current private or group health insurance coverage, or COBRA continuation, or a conversion policy, in effect or available.

·   The policy does not exclude the high cost medical condition.

·   The premiums are not the responsibility of an absent parent.

·   There is no enrollment in a Medi-Cal related pre-paid health plan.

The client’s health insurance policy must not be issued through the California Major Risk Medical Insurance Board.







15.01.06 Employer Group Health Plan (EGHP)



Effective January 1, 1991, OBRA 90 mandated that states pay health insurance premiums, deductibles, and co-payments for Medi-Cal recipients who are eligible for enrollment in an EGHP when it is cost effective.


In order to qualify for the EGHP program, the client must meet all the conditions listed in MPG 15.01.05.B above, and the health insurance must be available through an employer.


The state may also pay only the premiums for a non-Medi-Cal eligible, if the Medi-Cal eligible person’s enrollment in the health plan is dependent on the non-Medi-Cal person's enrollment.