Marquez

Pursuant to federal law, California’s Medi-Cal program requires Medi-Cal beneficiaries to utilize services available through any other health coverage (OHC) they may have before accessing Medi-Cal benefits. To this end, respondent State Department of Health Care Services (DHCS) maintains a database with codes that indicate whether a Medi-Cal beneficiary has OHC and, to some extent, the type or scope of that coverage. These codes are available to Medi-Cal providers when a beneficiary seeks services.

Medi-Cal beneficiaries Maria Marquez, Maricella Rivera, and Robert Planthold (petitioners) sought a writ of mandate in the trial court under Code of Civil Procedure section 1085 to require respondents’ compliance with their duties in administering this and related aspects of the Medi-Cal program. Because DHCS allegedly permits Medi-Cal providers to refuse nonemergency services to beneficiaries with OHC, and because the codes related to OHC are not always correct and the information maintained in the DHCS database is limited, petitioners argued that beneficiaries may be improperly denied service and referred to other health care providers even when, in reality, there is no OHC…