California Department of Social Services - State Hearings Division
Notes from the Training Bureau - August 8, 2003

The DHS has requested that two categories of cases be added to those decisions that must be written as proposed decisions. Cases involving stairway lifts must be written as proposed decisions.

In Blue v. Bonta, (2002) 99 Cal Application. 4th 980, the California Court of Appeals concluded that the DHS wrongly excluded stairway chairlifts from the scope of Medi-Cal coverage. Pursuant to Blue, the DHS repealed a new regulation at 22 California Code of regulations (CCR) 51160(e) that stated that stairway chairlifts are not a Medi-Cal covered benefit.

Stairway chairlifts may be authorized when they are medically necessary. The court added: "The Department retains the discretion to restrict stair lift coverage to those Medi-Cal patients for whom it is actually medically necessary and may subject this coverage to cost utilization controls, if other economical means exist to remedy the problem."

Cases involving claims for direct reimbursement of medical bills paid are also to be written as proposed decisions. In Conlan v. Bonta, (2002) 102 Cal. App. 4th 745, 751 California Court of Appeals, First Appellate District, the petitioners asked the Court to order the CDHS to set aside fair hearing decisions which had denied requests to order reimbursement to the petitioners for medical costs incurred within 90 days prior to the date of Medi-Cal application and for erroneously paid pharmacy co-payments.

The Court ordered CDHS to "ensure that Medi-Cal recipients entitled to reimbursement for covered services during the retroactivity period [i.e., 90 days prior to the Medi-Cal application date] are promptly reimbursed."

The court discussed the role of the ALJ and in the Disposition required "... ALJs to determine what amounts, if any, each petitioner is entitled to receive..." and order "direct reimbursement" or allow CDHS "a reasonable period of time in which to implement new procedures designed to effect such reimbursement."

The DHS is in the process of implementing a plan to comply with Conlan so that the plan can be approved by the court. Until such plan is approved, it is DHS' position that there is no jurisdiction for an Administrative Law Judge to order DHS to reimburse a claimant for payments made out of pocket for Medi-Cal covered services.

DHS' position is that if a claimant requests a hearing seeking reimbursement for Medi-Cal covered services, and if the DHS has not evaluated such request or issued a notice of action denying such request, the request for hearing should be dismissed because there has been no adverse action. At present, DHS has not evaluated any reimbursement requests because there has been no implementation plan set up and approved by the court.

Judges should then advise the claimant to contact DHS.

Claimants may contact DHS as follows:

Fee-for-service Claims

DHS Provider Services
c/o EDS
3215 Prospect Park Dr. Room 150
Sacramento, CA 95670
(916) 636-1980

Denti-Cal Claims

DHS
Medi-Cal Dental Services Branch
Attn: Patricia Owens RDII
P.O. Box 942732
Sacramento, CA 94299-0004

(916) 464-5703

Medi-Cal Managed Care Claims

Call your Managed Care Plan-member services department

If the managed care plan member services department is not able to help, the following phone number is available for the managed care ombudsman.

1-888-452-8609 Office of the Ombudsman

DHS anticipates that it will not have an implementation plan approved by the court for several months. In the interim, when a claimant writes or calls the applicable DHS contact, the claimant will be guided concerning the procedure and documentation necessary for consideration for reimbursement once the implementation plan has been approved and is in place.

Once a plan is in place, DHS will evaluate reimbursement requests. DHS will issue a notice of action if it denies all or part of a request. The claimant will have hearing rights on any such denial.