Overpayment Rules

The following basic overpayment rules must be kept in mind when evaluating potential MC overpayments.

  1. There are no administrative overpayments in the MC program.
  2. The actual eligibility status and SOC based on the correct income, property and other circumstances must be used when determining potential MC overpayments.
  3. When changes in income or other circumstances are unreported, or not reported within ten days, a potential MC overpayment may occur.
  4. Do not assume that a MC overpayment exists based on a CalWORKs or other welfare program overpayment determination for the same period.
  5. EWs do NOT determine if fraud is involved in a potential MC overpayment. The determination of fraud is the responsibility of the DHCS Recovery Section or the Investigation field office.
  6. All potential MC overpayments of $100 or more must be referred to the local DHCS Investigations Unit.
  7. Prior to computing a potential MC overpayment, the EW must review the individual’s eligibility for any other MC programs. For example, one or more members could be eligible for one of the Federal Poverty Level (FPL) or property waiver programs. Because these and other programs can have different property or income rules, a potential overpayment for any MC case may not apply to the individual qualifying for these programs.
  8. If the potential MC overpayment is due to willful failure to report facts and there was a person acting on behalf of the client, the EW MUST determine whether the client is competent to handle his/her affairs.

Competency as Related to MC Overpayments

If the client is...

Then the EW must...

Competent
  • Require the client to act on his/her own behalf in the future, AND
  • Refer the case to the local DHCS Investigation Unit.

Incompetent
  • Refer the case to Adult/Child Protective Services and/or the Public Guardian or conservator to ensure that the client’s interests are protected.
  • Refer the case to the local DHCS Investigation Unit.

Overpayment Responsibility in Cases with Authorized Representative

There is no statutory authority which enables DHCS to recover an overpayment from individuals, law firms, or organizations who represent the applicant/client and have been named as an Authorized Representative (A/R) by signing the form “Appointment of Representative” (MC 306).

However, any A/R who is suspected of intentionally and fraudulently providing false information to the EW or “coaching” the applicant/client and such action results in an overpayment, must be referred to the DHCS Investigation Unit for possible civil or criminal prosecution. The EW must complete the “Confidential Medi-Cal Complaint Report” (MC 609) and refer this as a potential MC overpayment.

Related Topics

Types of Potential Medi-Cal Overpayments

Overpayment Examples

Overpayment Overview