Title 22 CCR §50746 states the following:

The county department shall not provide a Medi-Cal card or request that a Medi-Cal card be issued by the Department to any Medi-Cal beneficiary more than one year subsequent to the month of service, unless one of the following conditions is met:

(1) A court action requires that a Medi-Cal card be issued.

(2) An adopted state hearing decision or other administrative hearing decision requires a redetermination of eligibility which results in the beneficiary's entitlement to a Medi-Cal card.

(3) An adopted state hearing decision states that, due to county department or Department administrative error, a Medi-Cal card for a month was not received by the beneficiary.

(4) The Department requests that the Medi-Cal card be issued.

(5) The county department determines that an administrative error has occurred.

In some cases a claimant will request a hearing because he/she has received a bill for medical services rendered more than one year ago. The claimant was a Medi-Cal recipient at the time the medical services were rendered. For one reason or another, the medical bill was unpaid. The claimant now seeks to have Medi-Cal pay the unpaid bill.

Section 50746 explains under what circumstances the county or DHS may provide a Medi-Cal card more than one year from the date of service. This newsletter item addresses what an Administrative Law Judge may do if none of §§50746(a)(1), (2), (3) or (5) above apply. The following example illustrates the issue:

A claimant was rushed to a hospital by emergency ambulance in March 1996. A Medi-Cal application was taken on behalf of the claimant at the hospital. Medi-Cal was approved for the claimant effective March 1996. The claimant was treated and eventually recovered from his injuries. Medi-Cal paid for his hospital bill.

Five years later he receives a $2100 bill from the ambulance company for transporting him to the hospital. The claimant testifies at the hearing that he was unaware that Medi-Cal had not paid for the ambulance service until he received the bill. The claimant did not give anyone at the ambulance company his Medi-Cal card when he was rushed to the hospital because his Medi-Cal application was not processed until after he arrived at the hospital.

The claimant now wants Medi-Cal to pay the ambulance company bill. The county representative contends that the county may not issue a letter of authorization for Medi-Cal for March 1996 because that date is more than one year ago. The county notes that Medi-Cal eligibility was established for the claimant for March 1996. The county states that since Medi-Cal eligibility was established and there is no administrative error, nor court action requiring a Medi-Cal card be issued, it may not issue a card for March 1996.

The county is correct that there is no administrative error or court action requiring the county to issue a Medi-Cal card. Sections 50746(a)(1), (2), (3) and (5) do not apply. However, section (a)(4) may apply.

A judge should order the county to refer the matter to the CDHS consistent with MEPM §14E to consider whether to request that a Medi-Cal card be issued for March 1996. MEPM §14E states at page 2, "If the county finds that an administrative error does not exist in a particular situation, but extenuating circumstances exist beyond the beneficiary’s control, the county may contact the Medi-Cal Eligibility Branch for assistance. Please be advised that billing problems are not by themselves considered an extenuating circumstance.... An example of an extenuating circumstance beyond a beneficiary’s control would be a medical condition that severely impaired his/her functioning. Additionally, the beneficiary would need to describe how this reduced function prevented him/her from giving the provider(s) the necessary documentation of his/her Medi-Cal eligibility."

MEPM page 14E-3 then explains that the Medi-Cal Eligibility Branch will evaluate whether a letter of authorization should be issued pursuant to §50746(a)(4). It further explains the procedure the county should follow to seek DHS authorization for Medi-Cal card issuance.

A judge may order the county to refer a case such as the example cited above to Medi-Cal Eligibility Branch Chief, Over One-Year Letter Analyst, 714 P. St., Room 1650, Sacramento, California 95814.