Fix Medi-Cal Share of Cost back date Retroactively

Can Medi-Cal Share of Cost Be Back Dates – Corrected for Past Months?

Sometimes, yes. But back dated “retroactive Medi-Cal” can mean several different things, and the rules are not the same for each one.

Before someone tells you “you can only go back three months” or “you can never go back,” first determine which situation you actually have.

You already had Medi-Cal with a Share of Cost, but a health or dental insurance premium should have lowered it.
The county calculated your Share of Cost incorrectly or failed to apply a deduction you reported.
You have medical or dental bills from earlier months that may affect your Share of Cost.
You were not yet on Medi-Cal and are asking for retroactive Medi-Cal for services received before your application.

Those are different issues with different rules.

See my web page — Medi-Cal Share of Cost — Start Here.
See my web page — Medical Expenses That May Lower Share of Cost .

Health & Dental Insurance Premiums Can Lower Countable Income

California Medi-Cal regulations specifically provide that qualifying health insurance premiums are deducted from income.

California Code of Regulations, Title 22 §50555.2 — Health Insurance Premiums states that health insurance premiums shall be deducted if paid by and purchased for a person in the family.
- If health insurance payments are made less often than monthly, §50555.2(b) provides that they are averaged on a monthly basis.
California Code of Regulations, Title 22 §50653 — Determination of Share of Cost Share of Cost is calculated from net nonexempt income, and it must be redetermined when income or another factor affecting Share of Cost changes.

This is not merely our interpretation. The California Department of Health Care Services gives counties a specific example in All DHCS All County Welfare Directors Letter 20-24 — see the dental-premium example on page 5 in which a couple pays $30 per month for supplemental dental insurance. DHCS deducts that $30 dental premium when calculating Medi-Cal eligibility.

Important distinction: An insurance premium may reduce the income Medi-Cal counts when determining eligibility and Share of Cost. That is different from simply paying a doctor bill to meet an existing Share of Cost for the month.

What If Your Share of Cost Should Have Been Lower in an Earlier Month?

California regulations specifically address this situation.

Under 22 CCR §50653.3, when a change in income or other circumstances decreases Share of Cost and the beneficiary reports it timely, the county must:

Change the ongoing Share of Cost;
Determine what the Share of Cost should have been for the month in which the change occurred; and
Provide the applicable correction or adjustment for the affected month or months.

If the change was not reported timely, §50653.3 provides a more restrictive rule. A retroactive adjustment generally is not made unless the county determines that there was good cause for the late reporting.

What If the County Made the Mistake?

There is an even more direct rule for county administrative error. 22 CCR §50653.7 states that an administrative error that causes Share of Cost to be higher than the correct amount shall be adjusted under §50653.3(a).

22 CCR §50653.7 — Changes in Share of Cost Determination Due to Administrative Error

DHCS even has an official county procedure entitled “Processing Cases When a Share of Cost Has Been Reduced Retroactively.” It explains how counties are to handle situations in which a beneficiary’s SOC is later determined to have been too high.

DHCS Medi-Cal Eligibility Procedures Manual — Article 12, Share of Cost

What If Your Insurance Company Shows an Earlier Effective Date?

Sometimes an insurance company issues written proof today showing that coverage was effective in an earlier month.

For example, a carrier might issue a verification letter in August showing:

Dental coverage effective May 1;
A $425 monthly premium;
Coverage continuing without a termination date.

An earlier insurance effective date is important evidence, but it does not by itself guarantee that the county must automatically apply the premium to every earlier month.

The better approach is to document exactly what happened and ask the county to determine the correct Share of Cost for each affected month.

Get This Documentation From the Insurance Company

Coverage Verification showing the actual effective date;
Premium amount;
A month-by-month billing or premium ledger;
The date each month’s premium became due;
Proof of payment or draft, if available;
Confirmation that coverage was actually in force for the earlier months.
Email [email protected]

Reporting Other Health Coverage

Under 22 CCR §50763, a Medi-Cal beneficiary must report a change in other health care coverage no later than 10 calendar days from the date the beneficiary was notified of the change by the employer or insurer.

That language may be particularly important when an insurer does not issue the written confirmation of an earlier effective date until later. It does not automatically decide whether the earlier premium must be credited, but it is an important regulation to include with the request.

22 CCR §50763 — Beneficiary Responsibility: Other Health Care Coverage

Do not rely only on a telephone conversation. Submit the documentation in writing and ask the county for a written eligibility determination for each month.

Federal Medicaid Rules on Medical Expenses & Insurance Premiums

Federal Medicaid regulations also recognize health insurance premiums in medically needy income and spend-down calculations.

Under 42 CFR §435.831:

Medicare and other health insurance premiums are included among deductible incurred medical expenses;
An expense is incurred when liability for the expense arises;
Paid and unpaid qualifying expenses can be relevant under the medically needy rules; and
When expenses are handled chronologically, an insurance premium is associated with the date the premium amount is due.

This federal regulation is useful supporting authority when dealing with a Medi-Cal medically needy Share of Cost case. However, it should not be read as a guarantee that California must accept every insurance policy that an insurer later gives an earlier effective date.

42 CFR §435.831 — Medicaid Medically Needy Income Eligibility

Separate Rule: Retroactive Medi-Cal Before You Applied

There is also a completely separate rule commonly called “three-month retroactive Medi-Cal.”

This applies when someone is applying for Medi-Cal and had medical or dental services during the three months immediately before the application month.

Under 22 CCR §50197, an applicant may qualify in one or more of those three prior months if:

The person would have been eligible for Medi-Cal in that month;
The person received health services in that month; and
The other requirements of the regulation are met.

Under 22 CCR §50148, a request for retroactive coverage may be made in writing, on the application, or on the Statement of Facts. The application for retroactive coverage generally must be submitted within one year of the month being requested.

DHCS also explains that retroactive Medi-Cal may help with unpaid medical or dental bills from those three months and, in some situations, reimbursement for bills already paid.

Do not confuse this three-month rule with correcting an existing Medi-Cal beneficiary’s Share of Cost. An SOC correction because an insurance-premium deduction was omitted is primarily addressed by the Share of Cost and reporting regulations discussed above.

How to Ask Medi-Cal to Correct Earlier Months

Step 1 — Gather Your Evidence

Your Medi-Cal Notice of Action showing the original Share of Cost;
The insurance company’s Coverage Verification;
The policy effective date;
Premium invoices or a month-by-month carrier ledger;
Proof of payment, if available;
Any earlier documents you submitted to the county;
A list of the exact months you want reviewed.
Email [email protected]

See my web page — How to Upload Documents to BenefitsCal.

Step 2 — Request a Written Recalculation

Sample request:

I am requesting that the county review and recalculate my Medi-Cal eligibility and Share of Cost for the following months: __________.

Attached is documentation showing health or dental insurance coverage effective __________ with a monthly premium of $__________.

California Code of Regulations Title 22 §50555.2 provides for the deduction of qualifying health insurance premiums. Sections 50653 and 50653.3 require Share of Cost to be redetermined when a factor affecting Share of Cost changes and provide procedures when that change decreases Share of Cost.

Please determine what my Share of Cost should have been for each affected month and make any correction required by Medi-Cal rules.

If you need additional documentation, please tell me specifically what is required.

If the county determines that an earlier month cannot be corrected, please issue a written Notice of Action stating the factual reason and the legal authority relied upon for that determination.

Step 3 — If Someone Just Tells You “No”

Ask that the determination be put in writing.
Ask for the specific regulation or policy relied upon.
Keep copies of everything submitted.
Keep the upload confirmation from BenefitsCal.
If you disagree with the written Notice of Action, consider requesting a State Hearing.

See my web page — Medi-Cal Appeals & State Hearings.

The California Department of Social Services generally gives you 90 days to request a State Hearing after a county or DHCS action.

California Department of Social Services — State Hearing Requests

Legal Authority, DHCS Guidance & Sources

Important: This page provides general educational information about Medi-Cal eligibility and Share of Cost rules. Individual facts matter, and county determinations may need to be reviewed through the formal Notice of Action and State Hearing process. Steve Shorr is a licensed California insurance agent and does not provide legal advice.

How to Fix Medi-Cal Share of Cost Retroactively