Share of Cost for Medi-Cal Members
- Participating Physician Groups (PPG)
Certain Medi-Cal members may be required to pay, or agree to pay, a monthly share of cost (SOC) toward their medical expenses before Medi-Cal becomes financially responsible. SOC is similar to a deductible. Typically, a Medi-Cal member's SOC is determined by the county welfare department and is based on the member's income in excess of maintenance need levels, which is defined as the amount of an individual's income that Medi-Cal determines is used to cover living expenses, such as food, clothing and housing. Medi-Cal rules require that members pay income in excess of their maintenance need level toward medical bills before Medi-Cal begins to pay.
Providers must access the Medi-Cal eligibility verification system to determine whether a member must pay an SOC. The message returned by the eligibility system includes the SOC dollar amount the member must pay. After accessing the system via one of the following methods, the system sends a message to the provider, indicating the member's SOC:
- Point of service (POS) device.
- Automated Eligibility Verification System (AEVS), which is an interactive response system that allows providers to verify current member eligibility or for the prior 12 months, obtain information about SOC, identify any service restrictions placed on the member, and clear SOC liability.
- State-approved vendor software.
- Medi-Cal website at www.medi-cal.ca.gov.
When the provider verifies a member's eligibility and an SOC is indicated for the member, it will be under one of two scenarios, as follows:
- Met share of cost - This means the member is active with Health Net and SOC has been met. In order for a certification date to display in the Medi-Cal Eligibility Data System (MEDS), a county eligibility worker must manually add information for each member, each month. AEVS accesses the most current member information for a specific month of eligibility. After eligibility is confirmed, a 10-character eligibility verification confirmation (EVC) number is provided. Health Net recommends that providers enter the EVC in the remarks area of the claim; however, the EVC is not required for claims processing.
- Unmet share of cost - This means the member is a potential Health Net member for which SOC has not been met. These members must pay their SOC in order to be eligible for services with Health Net. Health Net designates these members as eligible when Health Net is listed as the health plan, but the SOC has not been met. The member is listed as "Cancelled Pending a Potential Enrollee."
If the member has not met SOC, no EVC number is provided unless the member is dually eligible (eligible for services under more than one aid code). For a dually eligible member who is eligible for certain services with no SOC and the remaining services with an SOC, the aid code and corresponding eligibility message and an EVC number are given in the eligibility response for the non-SOC aid code only. An SOC message is then given for the SOC aid code.
Medi-Cal does not provide payment for provider services until the member's monthly SOC has been certified online. Certifying SOC means that the Medi-Cal eligibility verification system shows the member has paid or become obligated (as defined in the Obligating Payment section below) for the entire monthly dollar SOC amount owed.
When a member has fulfilled his or her SOC, the provider must access the Medi-Cal eligibility verification system and enter his or her provider number, provider identification number (PIN), member identification number, member identification card (BIC) issue date, billing code, and service charge. This clears the member's SOC responsibility. SOC information is updated, and a response is displayed on the screen or relayed over the telephone.
Several clearance transactions may be required to fully certify SOC. In other words, providers must continue to clear SOC until it is completely certified. Clearing SOC is also referred to as "spending down" the SOC. Providers must perform an SOC clearance transaction immediately upon receiving payment or accepting obligation from the member for services rendered. Delays in performing the SOC clearance transaction may prevent the member from receiving other medically necessary services.
Providers should submit only one SOC clearance transaction for each rendered service used to clear the member's SOC, even if a payment plan is used to meet the obligation. All medically necessary health services, including medical services, supplies, devices and prescription medications, whether
Medi-Cal covered or not, can be used to meet SOC for Medi-Cal and County Medical Services Program (CMSP) purposes.
Autocertification of SOC
In some cases, such as with long-term care (LTC) services, auto-certification can occur and a certification date will not be displayed for SOC members in MEDS. The auto-certification process works when the Statewide Automated Welfare Systems (SAWS) sends a transaction to MEDS that allows the SOC to be automatically certified each month and leaves it up to the facility to collect the SOC. This allows the member to be enrolled in the health plan.
When a provider checks eligibility and receives an EVC for services, this is an indication that the SOC has been met. If the member has not met the SOC, MEDS will show a health care plan (HCP) status code of 55 with eligibility verification requiring SOC spend down.
Although there may be no certification date for a member, they are still managed care- or plan-eligible regardless of if the member has met their SOC.
Providers may collect SOC payments from members on the date that services are rendered, or providers may allow a member to obligate payment for rendered services. Obligating payment means the provider allows the member to pay for the services at a later date or through a payment plan. The provider must use obligated payments to clear SOC. SOC obligation agreements are between the member and the provider and should be in writing and signed by both parties for protection. There is no reimbursement for SOC payments obligated but not paid by the member.
Frequently Asked Questions
Q: Is it an error that members are being enrolled into Health Net when their SOC has not been met yet?
A: No, it's not an error that members are being enrolled into Health Net when their SOC has not been met yet. Members are determined to be eligible for enrollment into the plan. Eligibility is activated in the plan whenever the member's SOC has been satisfied. These members have a status code of 55, which states that they are eligible for Medi-Cal through the plan but must first satisfy their SOC.
Q: Is there a process in which members can be enrolled in Health Net before they have fully met their SOC and pay their SOC amount directly to the managed care plan?
A: Yes, there is a process by which members are enrolled in Health Net before they have fully met their SOC, and this process is performed on a county level. The SOC is never directly paid to the managed care plan; the SOC is always paid at the location where the member receives his or her services. The provider will report to the plan that the member's SOC has been satisfied, which triggers activation of eligibility for that month. At that point, the plan will begin paying for medical services incurred.
Q: If a member shows an active enrollment and an SOC that has not been certified, why is the member showing an HCP Stat 01 (enrolled in plan) instead of a 55 hold?
A: This could be an indication of an LTC member, in which the eligibility has been automatically certified on the first of the month, and has been coded correctly in MEDS (eligibility status beginning with a 1 or 2). The screen displays correct eligibility, and the member should have no issues receiving medical services. With most LTC members, their SOC gets certified on the first of the month when their bill gets paid. Even though the provider inquiry screen displays "LTC SOC/Spend down," an EVC number is provided, which is an indication that the SOC has already been certified and a billing number is provided to bill Medi-Cal eligible services.
Q: When a member is in LTC, does the system automatically certify the SOC or is it the facilities' responsibility?
A: SOC is certified differently for LTC members with specific aid codes. The system will automatically certify the SOC, in some cases. LTC facilities may be required to perform SOC clearance transactions when a recipient with an unmet SOC is admitted, or when a recipient's SOC exceeds the total charges of the Medi-Cal rate for a given month's stay. Providers receiving an eligibility verification that indicates a member has an LTC SOC should not clear the SOC online; the member is automatically eligible as of the first of the month. The facility does not need to clear the SOC first but can bill the member for the SOC amount.
For more information about using the Medi-Cal website, access the Quick Start Guide on the Medi-Cal website at www.medi-cal.ca.gov/pubs/quickstart.htm.