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  #1  
Old 10-05-2017, 09:21 AM
retre retre is offline
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Default Medi-Cal emergency care out of state

Hey,

This is not necessarily an actuarial question, but I hoping someone can point me to the right rules.

Is there a good resource for determining whether care should be covered by Medi-Cal for emergent out of state care?

My good friend has a loved one that is a Medi-Cal beneficiary. He was seriously injured out of state. They are worrying about what should be covered.

I have been trying to look at resources on the out of state coverage. I can tell that the ER should be covered, but I can't tell whether the stabilization period as an inpatient (until he can be safely transported back to CA) should be covered. Long term, they believe that they will receive reimbursement for the cost of the care (via other avenues), but are worried about bills now.

Any resources that I can be directed to would be great.

Thanks! Feel free to PM me, if you want/need more details to help.
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  #2  
Old 10-05-2017, 11:46 AM
tommie frazier tommie frazier is offline
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prefaced with this: I know 0 about MediCal. so my comments are just theory. (AO = AO + 1)

ER followed by continuous confinement as IP should be covered as necessary. If they then require a transfer to instate as soon as stable enough...I could see that.
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  #3  
Old 10-05-2017, 12:31 PM
Maine-iac's Avatar
Maine-iac Maine-iac is offline
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This is from the state regulations. It sounds like they would be covered unless they are overseas. But they should be talking to the pre-authorization folks about the continuing inpatient stay. It should be covered as long as its not a medically good idea to move them, but the sooner they get an authorization, the easier it will be to make sure the bills get paid.

540-1

Out-of-state medical care is limited to the following:



(a) (1) When an emergency arises from accident, injury or illness; or



(2) Where the health of the individual would be endangered if care and services are postponed until it is feasible that he/she return to California; or



(3) Where the health of the individual would be endangered if he/she undertook travel to return to California; or



(4) When it is customary practice in border communities for residents to use medical resources in adjacent areas outside the State; or



(5) When an out-of-state treatment plan has been proposed by the beneficiary's attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.



(6) Prior authorization is required for all out-of-state services, except:



(A) Emergency services as defined in 51056.



(B) Services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services.



(b) No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico.
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  #4  
Old 10-05-2017, 05:43 PM
retre retre is offline
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Quote:
Originally Posted by Maine-iac View Post
This is from the state regulations. It sounds like they would be covered unless they are overseas. But they should be talking to the pre-authorization folks about the continuing inpatient stay. It should be covered as long as its not a medically good idea to move them, but the sooner they get an authorization, the easier it will be to make sure the bills get paid.

540-1

Out-of-state medical care is limited to the following:



(a) (1) When an emergency arises from accident, injury or illness; or



(2) Where the health of the individual would be endangered if care and services are postponed until it is feasible that he/she return to California; or



(3) Where the health of the individual would be endangered if he/she undertook travel to return to California; or



(4) When it is customary practice in border communities for residents to use medical resources in adjacent areas outside the State; or



(5) When an out-of-state treatment plan has been proposed by the beneficiary's attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.



(6) Prior authorization is required for all out-of-state services, except:



(A) Emergency services as defined in 51056.



(B) Services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services.



(b) No services are covered outside the United States, except for emergency services requiring hospitalization in Canada or Mexico.
THANKS!!! This is exactly what I was looking for but couldn't find it on my own.
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  #5  
Old 10-08-2017, 10:55 AM
10sh3r0 10sh3r0 is offline
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not sure if this will help and not an actuary (yet) but worked for a major Medi-Cal plan modeling utilization. seeing out of state claims wasn't uncommon but make sure you get a hold of the insurer first. make sure everything is straightened out. im a bit paranoid w/ Medi-Cal plans based on the circus that i saw on the inside.
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