§ 50786. Action on Overpayment -Department of Health Services or County Unit Contracted to Collect Overpayments.

(a) Upon receipt of a potential overpayment referral, the Department's Recovery Section or the county unit contracted to collect overpayments shall:

(1) Determine the amount of Medi-Cal benefits received by the beneficiary for the period in which there was a potential overpayment.

(2) Compute the actual overpayment in accordance with the following:

(A) When the potential overpayment was due to excess property, the actual overpayment shall be the lesser of the:

1. Actual cost of services paid by the Department during that period of consecutive months in which there was excess property throughout each month.

2. Amount of property in excess of the property limit during that period of consecutive months in which there was excess property throughout each month. This excess amount shall be determined as follows:

a. Compute the excess property at the lowest point in the month for each month.

b. The highest monthly amount determined in a. shall be the amount of the excess property for the entire period of consecutive months.

(B) When the potential overpayment was due to increased share of cost, the actual overpayment shall be the lesser of the:

1. Actual cost of services received in the month(s) which were paid by the Department.

2. Amount of the increased share of cost for the month(s) in which services were received which were paid by the Department.

(C) When the overpayment was due to excess property and increased share of cost, the actual overpayment shall be a combination of (A) and (B).

(D) When the potential overpayment was due to other factors which result in ineligibility the overpayment shall be the actual cost of services paid by the Department.

(E) Potential overpayments, due to beneficiary possession of other health coverage that is not subject to post-services reimbursement, shall be processed by the Department to determine and recover actual overpayments in all cases. The actual overpayment in such cases shall be the actual cost of services paid by the Department which would have been covered by private health insurance or other health coverage, had the coverage been known to the Department. The actual overpayment shall not include any costs which can be recovered directly by the Department from the health insurance carrier or other source.

(3) Refer those cases where there appears there may be fraud to the Investigations Branch of the Department.

(4) Take appropriate action to collect overpayments in accordance with Section 50787.

HISTORY

1. Amendment filed 12-30-81 as an emergency; effective upon filing (Register 82, No. 1). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 4-29-82.

2. Certificate of Compliance transmitted to OAL 4-23-82 and filed 5-12-82 (Register 82, No. 20).

3. Amendment filed 5-12-82; effective thirtieth day thereafter (Register 82, No. 20).

4. Amendment of subsection (a)(2)(A)2. filed 6-3-87; operative 7-3-87 (Register 87, No. 24).

5. Amendment of subsections (a)(2)(B)1. and 2. and Note filed 4-13-93; operative 5-13-93 (Register 93, No. 16).

Note

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 11004, 14005.9, 14009 and 14016.4, Welfare and Institutions Code.