DHS Must Reimburse Medi-Cal Beneficiaries for Prior Care, Court Rules
A state Court of Appeal on Monday said the Department of Health Services must order health care providers to reimburse Medi-Cal beneficiaries for medical costs incurred up to three months prior to the time the beneficiaries applied for the program, as well as costs beneficiaries incurred during the application process, the San Francisco Chronicle reports.
The appeals court upheld a Superior Court's decision in a lawsuit filed in June 1997 by three Bay Area residents seeking reimbursement. The court said federal law states that Medicaid beneficiaries are entitled to reimbursement for costs that would normally be covered by Medicaid and were incurred during three months prior to application and during the application process for care.
The ruling requires DHS to order health care providers to reimburse beneficiaries for the costs of prior care.
Prior to the ruling, providers would have to contact DHS to arrange reimbursement at the beneficiaries' request, according to Michael Keys, an attorney involved in the suit. Medi-Cal typically pays providers 50% to 60% of market-rate medical charges, but patients must be fully reimbursed for what they initially paid providers, Keys said.
Under the ruling, providers who refuse to reimburse beneficiaries can be suspended from Medi-Cal or fined. The state must pay the beneficiary directly if the provider is unable or unwilling to make the payment within 90 days, but the state will reimburse the beneficiary only at the Medi-Cal rate.
DHS spokesperson Ken August said department officials have not yet decided if they will file an appeal (Egelko, San Francisco Chronicle, 8/17).