Column 16 Medi-cal follow up more DDS

A reader called and told me that I should be cautious in encouraging people to take advantage of the new MAGI Medi-CAL benefits.  "My son had Medi-CAL and later was hit with a lien to pay back the benefits that were provided to him." I am grateful to the connections I have made at Covered Shasta for providing a little bit of insight.  Unfortunately, I did not have the specifics about the individual case, but I did receive this response from Veronica Lewis, Staff Analyst.  It sounded as if he might have had a 3rd party also pay some of his bills and that is why he was required to pay back some of the funds. Here is her response:

"Without additional information, it is difficult to respond to this individual's specific circumstances. 

The individual should contact the Medi-Cal (MC) Third Party Liability and Recovery Division (TPLRD).  The TPLRD Division is responsible for ensuring the MC program complies with laws and regulations relating legal liabilities of a third parties for health care services and workman compensation related injuries to beneficiaries and ensuring that MC is the payer of last resort.  Third parties are individuals or entities that are, or may become, liable to pay all or part of the medical costs provided to the Medi-Cal beneficiary The TPLRD can be reached at:  


One more week where we agents do not have our finalized status to write with Covered California.  We are hoping the "bugs" will be worked out by the time we do.  In addition it is my understanding that there are no local Certified Enrollment Counselors (CEC) either.  They are all waiting for the testing and final processing. In the meantime for those that want to work with a licensed agent or CEC, be patient.


A little more information on the Pediatric Dental  benefits:  Starting January 1, 2014, the Patient Protection and Affordable Care Act of 2010 (ACA) will require Small Group health insurance to cover essential health benefits (EHBs). EHBs encompass 10 categories of health benefit coverage. One of these categories is "pediatric services, including oral and vision care." Pediatric EHBs are for children up to age 19.

While pediatric vision care is an embedded benefit within some medical plans, it can also  be  is a separate plan that carries a separate premium. Because pediatric dental care is an EHB, a pediatric compliant dental plan must be bundled with every medical plan in some way for small groups.   According to the Blue Shield underwriting guide "All applicants, including adults, applying for a health plan will need to select a pediatric dental plan. Although individuals 19 years of age and older must select a pediatric dental plan, they will not be eligible for benefits and the pediatric dental rate will not apply."  It sounds a little silly, but it appears that needs to be done to keep the plans in compliance.


The ACA has also made a number of important improvements intended to increase access to dental coverage for children in the small group health insurance market.

One of the most significant improvements to note is that pediatric dental EHBs are not subject to annual or lifetime dollar limits. You'll notice, for instance, there is no calendar-year maximum when accessing a participating provider, like a traditional PPO dental plan. Instead, the plans offer an out-of-pocket maximum cost to the individual..  This is quite a bit different then we are accustomed too. You will also note the orthodontia is included.  However, it must be a medical situation like a cleft palate for the plan to pay for those benefit.

Following is a summary of some of the benefits that will be included:


• Diagnostic and Preventive services: Prophylaxis services (cleanings), X-rays, initial and periodic oral examinations, consultations, topical fluoride treatment, space maintainers, and dental sealant treatments

• Restorative services: Fillings (amalgam, composite resin, acrylic, synthetic or plastic),


• Oral surgery: Extractions (including surgical), removal of impacted teeth, biopsy of oral tissues,

*Endodontics, Periodontics, crowns and Bridges


What will make this interesting in our area is the limited number of plans that actually have a large Preferred Provider dental network.  With the upward pressure on small group health plan rates and few plans that have a large network, the enrollee and employer are going to have some tough decisions to make.


This is another reason for small employers to consider the Early Renewal option on their group health plans.  This will allow them to postpone addressing this issue until the renewal date in 2014.