Court Orders

Craig v. Bonta

Public Guardian Referral for Incompetent Clients

A referral to the Public Guardian Office must be completed for clients discontinued from SSI/SSP who are receiving nursing facility services and who are eligible for MC under the Craig lawsuit. Public Guardian Referrals are initiated by Social Workers at the facilities.

Long Term Care (LTC) Individuals

Discontinued SSI/SSP recipients who have entered into a LTC facility must receive PRIORITY to minimize their accumulation of nonexempt resources resulting from receiving MC eligibility at no share-of-cost. A new code of “L” will be placed in the [Pickle Status] field on MEDS to identify clients who are discontinued from SSI/SSP due to entering LTC.

Hunt v Kizer

Applicants who are in LTC often have unpaid medical bills that may qualify to be used to reduce the current or future SOC.

  • The EW may use the “SOC Adjustment Worksheet (Hunt v. Kizer)” (SCD 1596) as a tool to organize and record submitted bills.
  • Send the bill(s) and the SCD 1596 to IDM.
  • Private medical insurance and Medicare must be billed first before the balance of the bill can be used to reduce the SOC.
  • If bills are incurred during retro months, the client can apply for Retroactive MC.
  • The EW must contact the provider to clarify any discrepancies on the bill.

Johnson v. Rank

The Johnson v Rank court decision specifies that LTC clients must be able to use necessary non-covered services which are not covered by Medi-Cal to help meet their SOC.

  • Effective October 1, 1989, all Medi-Cal recipients in LTC facilities must obtain a physician's prescription or order for any non-covered medical or remedial drug or service, when the cost is to be applied toward their share-of-cost amounts.
  • The LTC facility must ensure that a copy of the prescription or order is in the individual’s medical record.

Necessary Non-Covered Services

A medical service is considered “Non-Covered” if either of the following is true:

  • The medical service is given by a non-MC provider, or
  • The medical service falls into the category of services that requires an authorization before MC will pay and either an authorization request was not submitted or was denied.

Examples of Non-Covered medical services include, but are not limited to:

  • Podiatry services
  • Chiropractic services
  • Hearing aid batteries

Payment for Necessary Non-Covered Services

Payment for non-covered services will be accomplished in the following manner:

  • For services arranged through the LTC facility, payment will be made by the facility.
  • For services arranged and paid by the individual or their authorized representative, the bills or receipts must be submitted to the nursing home no later than two months after receipt of the service, supplies or drugs.
    • Bills/receipts provided to the nursing home at the beginning of the month (when the LTC SOC is normally paid) may be deducted from the current month's share of cost before paying the remaining SOC to the nursing home.
    • If the bill/receipt is submitted after the current month's SOC has been paid, it will be deducted from the SOC during the following month.

“Important Notice About Your Medi-Cal Benefits”

The MC 18 (formerly ID-104) “Important Notice About Your Medi-Cal Benefits”, must be issued and explained to all LTC clients.

  • The notice explains the LTC/SOC billing procedure which enables the client to pay for necessary medical expenses that are not paid by MC.
  • The EW must provide the MC 18 to:
    • New LTC individuals or individuals acting on their behalf.
    • LTC individuals at the time of redetermination.

Johnson v. Rank Payments to Clients

Payments received as a result of the Johnson v. Rank Court Order are exempt as income and exempt as a resource for six months from (and including) the month of receipt.

Note: The “Request for SOCO (Share of Cost Obligation) Transaction (SCD 1296 SOCO) is used when the MC recipient has paid medical expenses not covered by MC. The EW completes the form and submits it to the MTO to apply the amount toward the SOC in MEDS.

Pickle v. Rank

Individuals in LTC are not eligible for Pickle or DAC.

Reese v Kizer

Note: Due to MCCA rules effective 1/1/1990, community property share of income no longer applies. The information regarding Reese v Kizer is only for historical purposes.

Issue

Whether the community property share of income of a spouse/same-sex spouse/RDP in an LTC facility should be made available to the spouse/same-sex spouse/RDP at home.

Decision

This court order took effect in part on April 29, 1985, to the extent that the counties were ordered to divide community income only if requested to do so by the applicant/recipient.

AB 987 was subsequently enacted in September 1985. It required counties to automatically divide community income as of the date one spouse/same-sex spouse/RDP entered LTC or any medical facility. The first month that counties were required to use the new income amounts was December 1985.

LTC Prejudice Cases

Note: Due to MCCA rules effective 1/1/1990, community property share of income no longer applies to married spouses when one spouse enters LTC. The information regarding LTC Prejudice Cases is only for historical purposes.

Issue

AB 987 established the “automatic” division of community property when one spouse enters long-term care (LTC). The law became effective September 29, 1985 and required the Department of Health Services (DHCS) to immediately issue a notice to all LTC patients informing them of the new law.
However, DHCS did not publish this notice until March, 1986.

  1. Certain persons may have been eligible for retroactive Medi-Cal for the period September, 1985 through April, 1986 if the division of community property regulations had been applied.
  2. On April 18, 1988, DHCS mailed a notice to all LTC patients known to MEDS from September, 1985 through 1986 which informed them that they may apply for retroactive Medi-Cal for this period, as they may have been disadvantaged by the delay.
  3. EWs were required to review LTC cases in order to identify potentially eligible persons for retroactive Medi-Cal for the period September, 1985 through April, 1986. The case review period was 8/1/88 through 8/31/89.
     

Related Topics

Long Term Care (LTC)