EW Responsibility for OHC

Informing

EWs must inform MC applicants and recipients that:

Reporting OHC does not interfere with their eligibility for or use of MC benefits.
If health insurance coverage is available from any source, at no cost to the recipient, the applicant/recipient must enroll. If the applicant/recipient fails to cooperate by not enrolling in the plan, the EW must deny or discontinue MC eligibility.
- Note: Individuals who do not apply for available coverage that meets Minimum Essential Coverage (MEC) are not eligible for Advanced Premium Tax Credits (APTC).
Employer related health benefits which are available to an individual must be reported. If there is no cost, the benefits must be applied for and retained. The MC program may pay the health insurance premiums if it is determined to be cost effective.
Any health insurance payments received for health care services paid by MC must be reported and repaid.
Due to the confidentiality of Minor Consent Services, MC will not report OHC nor bill private insurance carriers for such services.

Note: Federal law requires that EWs inform Medi-Cal beneficiaries and applicants that they are not required to purchase Medigap insurance.

Identification

EWs must ask applicants and recipients if they have other health insurance when:

Interviewing CalWORKs or MC only applicants during the Intake process.
Completing a CalWORKs or MC only redetermination.
A CalWORKs or MC only client is or was recently employed.
A CalWORKs or MC only client obtains, loses or changes employment.
It is reported that an absent parent is employed, obtains, loses or changes jobs (OHC may be available for the dependents).
Child support payments are being made, as employment of the absent parent is strongly indicated.
A client reports veteran status, military service or union membership of a family member or an absent parent.
The client or absent parent is a student (who may have insurance through a school health plan).
Work history indicates national organization membership (such as the American Association of Retired Persons or National Retired Teachers Association, which offer health plans).
Earnings statements indicate health coverage deductions.
Other evidence indicates the client may have other health insurance.

EW Actions

EWs are required to determine the availability of OHC by reviewing the application and asking key questions.

The chart below describes the actions EWs must take to identify OHC:

If the Client...	Then the EW Must...
Indicates either on the application or verbally that other health insurance is available,	Interview the client further to determine if the health insurance policy is one listed.
Indicates the absent parent is: employed, was recently employed, retired, serving in the military, a veteran, a union member, or a student,	Ask the client additional questions to determine if other health insurance is available.
Has one of the health insurance policies listed in the following table	Complete the appropriate windows for each eligible person with other health coverage. Record premium paid by the client, to properly allow the premium payment as a deduction in the budget.

Good Cause

There may be instances where the applicant/recipient may have other health coverage available but is unable to access this coverage. The EW must explore good cause and obtain an affidavit about the situation. Good cause exists when:

There are geographic barriers to accessing the health coverage. OHC is considered unavailable when the health plan is limited to a specific geographic service area and the recipient lives outside that area or the health plan requires use of specified provider(s) and the beneficiary lives more than 60 miles or 60 minutes travel time from the specified provider(s).
There are domestic abuse issues. ]

If good cause exists, the EW must inform the Third Party Liability (TPL) OHC Unit to remove the OHC indicator and indicate the reason. The “Other Health Coverage Transmittal” (SCD 2265) was developed for this purpose.

DHCS cannot correct or remove the health insurance records that come through the Local Child Support Agency (LCSA) OHC data match or entered by Healthy Families (HF). In these situations, the EW should work with CS or HF to have the OHC record removed from the CS Administration OHC data match or HF. To communicate with the LCSA staff may complete and send the “Social Services Agency/Local Child Support Agency Communication Form” (SCD 1603) or call (866) 901-3212. For issues regarding HF on MEDS or HF carrier information, staff may call (800) 880-5305.

OHC Priority

The goal of DHCS Third Party Liability is to complete an OHC request within 30 days of receipt. However, due to staffing shortages it may take up to 60 days. Priority is given to victims of domestic violence, cases where the OHC information is preventing immediate access to care, and cases where the client has signed an affidavit that he/she never had OHC.

If the client never had the OHC, request the OHC record be put on the “no carrier match list” to prevent the next OHC tape match from resetting the OHC code. The OHC removal request must indicate “Attention Manager” and the reason for the urgent request.

DHCS will attempt to process these requests within 48 hours of receipt.

Note: Complete the SCD 2265 when faxing the requests. Do not submit multiple requests for the same person as this may add to the delay.

Adding (Or Changing) OHC

EWs must update CalSAWS when a new OHC coverage policy is reported or there are subsequent changes to the current health coverage information.

The Social Security office is responsible for collecting OHC information ONLY when making an initial SSI/SSP determination or redetermination. Any corrections of or updates to OHC information for SSI/SSP recipients must be completed by the EW.

The recipient's MEDS record must be updated for each month affected to ensure proper claims processing.

Exceptions

The following types of OHC should not be entered in the system:

Accident benefits
Automobile, Burial, and Life Insurance benefits
Casualty Workers Compensation benefits
Disability benefits
Medicare
Healthy Kids
Veteran's Administration (VA) benefits
Coverage under a PHP or HMO which the client has chosen as a Health Care Option (HCO).

Coverage under one of the mandatory two-plan model managed care plans: Anthem Blue Cross of California or Santa Clara Family Health Plan.

Removing OHC

A request to remove the OHC code from MEDS must be made when there is termination of coverage, or the individual does not have the coverage reported by other sources (i.e. MEDS shows coverage the client never had).

The recipient's MEDS record must be updated for each month affected to ensure proper claims processing.

Verification

In order to ensure that MC is the payer of last resort, termination of OHC must be verified prior to removing the OHC code from MEDS for individuals whose OHC has ended (or for individuals who never had OHC).

Acceptable verifications include:

A payroll or pension check stub which shows that health insurance deductions have stopped.
An Explanation of Benefits from the insurance carrier showing the policy termination date.
A termination letter from the health insurance carrier or employer showing the policy termination date.
- Note: If the termination letter indicates COBRA eligibility and the client has a high cost medical condition, refer the client to the Health Insurance Premium Payment program.
A “Sworn Statement” (SCD 101) by the client or representative stating he/she no longer has, or never had the OHC. The affidavit must include the coverage termination date, if known. The affidavit may be used when an erroneous OHC code appears on a client’s MC record after DHCS conducts a data match with an insurance carrier, domestic violence situations, or in any other situation where the client cannot verify termination. The affidavit may also be used when a custodial parent or guardian cannot verify termination of an absent parent’s insurance.

Scan the verification of OHC termination in IDM under F-1.

OHC Termination/Removal Process

To report termination or request removal of OHC the following steps must be taken:

Enter the correct information and insurance termination date (if applicable).
Complete the online form to request the removal of OHC.
1. Note: For website submissions, DHCS will send a generic e-mail to confirm that the request has been entered. The EW must check MEDS to verify that the changes are complete and correct.

Temporary OHC Removal

To remove OHC for immediate need cases, staff may use an EW15 or EW55 (for SSI/SSP cases) immediate need transaction to update the OHC Code for the current month to a value of “N.” Do not use other OHC values as this will display the incorrect OHC information to providers.

Do not use EW15 or EW55 transaction to change OHC carrier information (e.g. scope of coverage changes).