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Overpayment Examples
Potential Overpayment - Income
Example
Ms. Cartwright and her 3-year-old daughter were eligible for MC with no SOC. She was
receiving unemployment insurance.
On July 24th, she stopped receiving UIB and she started working; however, she did not report this to her EW until her redetermination in October. Her net non-exempt earnings are $2400/month. A potential overpayment must be computed for September and October, as Ms. Cartwright and her daughter received free MC, but Ms. Cartwright should have been evaluated for APTC and Non-MAGI MC with a SOC. The client received medical services in September ($10,000) and October ($500):
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Ms. Cartwright Example - Wages |
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July |
August |
September |
October |
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(7/24 she returns to work. A 10-day notice could not be issued in time to be effective for August) |
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(EW notified on 10/4 redetermination) |
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No O/P |
No O/P |
Cost of MC Services Paid by DHCS $10,000 |
Cost of MC Services Paid by DHCS $500 |
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Overpayment Amount $1,650 |
Overpayment Amount $500 |
The potential overpayment will be the lesser of:
- Cost of MC services which were paid by DHCS that were received in the potential overpayment month(s).
OR
- Amount of the increased SOC for the potential overpayment month(s) in which services were received and paid by DHCS.
Potential Overpayment - Property
Example
Mr. Talik has been on ABD Non-MAGI MC since March 2015. On January 2016, he inherited $20,000 which he failed to report to his EW until his redetermination in May 2016. He used some of the money in March to pay $1,100 for rent, and in April he used $19,300 to buy a new car; he is now within property limits.
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Mr. Talik Example - Wages |
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RD Due |
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Month Year |
January 2016 |
February 2016 |
March 2016 |
April 2016 |
May 2016 |
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Property |
$1,600 |
$21,600 |
$20,500 |
$1,200 |
$1,200 |
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MC Services Received |
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Cost of MC Services Paid by DHCS $300 |
Cost of MC Services Paid by DHCS $1,000 |
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Overpayment Calculation |
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Highest Excess Balance 21,600 - 3000 = $18,600 |
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Overpayment |
The overpayment is either $1300 ($300 February + $1000 March) or $18,600 based on the calculation for the overpayment. The lesser amount is $1,300; thus, Mr. Talik owes $1,300. |
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The property-based potential overpayment is determined by:
- Computing the lowest excess property balance in each month
- Selecting the highest excess property amount, and
- Reporting this amount as the potential overpayment amount.
The actual overpayment will be the lesser of:
- The total cost of services paid for by DHCS during the consecutive month period in which there was excess property throughout each of the months,
OR
- The highest monthly excess property balance for any single month in the potential overpayment period.
Related Topics
Types of Potential Medi-Cal Overpayments