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California Code, Welfare and Institutions Code - WIC § 14124.92

Current as of January 01, 2025 | Updated by Findlaw Staff

(a) The department may pay administrative expenses and make incentive payments to any county, state, or federal agency, or a contracting agent of the department for identifying and reporting third-party health care coverage held or offered to beneficiaries under this chapter.

(b) Unless the third-party health care coverage identified is excluded under subdivision (d) from the incentive payment plan, an agency or contractor may be entitled to an incentive payment if the agency or contractor does all of the following:

(1) Identifies a case of which the department was not previously aware.

(2) Provides to the department adequate and necessary information relevant to the third-party health care coverage in order to make a claim for benefits or reimbursement for services rendered that would otherwise be paid by Medi-Cal.

(3) Reports to the department the identified third-party health care coverage within 30 days of the date of discovery on a form approved by the department.

(c) In no event shall any one incentive for each case identified exceed one month of savings received by the department for benefits paid by the third-party health care coverage.

(d) Third-party health care coverage that does not qualify for the incentive payment plan under this section shall be identified by the department based on policy limitations and cost-effectiveness. The types of coverage that do not qualify under this section include those that to which any of the following apply:

(1) Not specifically intended to provide third-party health care coverage, such as coverage that provides life or car insurance benefits, periodic benefits for disability or hospitalization, or income protection.

(2) Coverage is limited to a specific diagnosis, unless the beneficiary has been diagnosed with a condition or disease specified in the coverage.

(3) Coverage is limited to a specific circumstance, such as accidental injury or dismemberment.

(4) Coverage is limited to one specific category of service.

(e) For the purposes of this section, “third-party health care coverage” means health care service plans, benefits, insurance policies, and funds, including those described in Section 14124.90.

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Cite this article: FindLaw.com - California Code, Welfare and Institutions Code - WIC § 14124.92 - last updated January 01, 2025 | https://codes.findlaw.com/ca/welfare-and-institutions-code/wic-sect-14124-92/

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