A 59 hold refers to a specific status where a recipient's enrollment is temporarily suspended, primarily due to a change in their status that is not related to a general hold on their Medi-Cal eligibility. This type of hold results in no capitation payments being made for the individual during the period of suspension.
Understanding the 59 Hold Status
The 59 hold is a code used in administrative systems to indicate that a person's enrollment cannot proceed or is temporarily paused because certain critical information about their status has changed. These changes are specific and exclude broader Medi-Cal eligibility issues.
Here's a breakdown of what constitutes a 59 hold:
- Enrollment Suspension: The core meaning is that an individual's enrollment is put on hold. This means they are not actively enrolled for benefit purposes during this period.
- Reason for Hold: The hold is triggered by changes in the recipient's personal or geographical data. Examples of such changes include:
- ZIP Code: A change in the recipient's residential ZIP code.
- County Code: A change in the county where the recipient resides.
- Aid Code: A modification to the specific aid code associated with their benefits.
- OHC Code Not Covered by Plan: Changes in 'Other Health Coverage' (OHC) codes that indicate coverage not compatible with or included in the current plan.
- Exclusion: It's crucial to note that this hold does not pertain to general suspensions or holds on Medi-Cal eligibility itself. It's a more granular issue related to specific recipient data.
- Financial Impact: When a 59 hold is in effect, no capitation payments are issued. Capitation payments are typically fixed, per-member payments made to healthcare plans or providers for a set period, regardless of services used. The absence of these payments signifies that the individual is not considered actively covered or accounted for in the payment cycle during the hold.
Key Aspects of a 59 Hold
To further clarify, consider the following table summarizing the 59 hold:
| Code | Description | Capitation Paid? |
|---|---|---|
| 59 | Enrollment held due to a change in the recipient's status (e.g., ZIP code, county code, aid code, or OHC code not covered by the plan), other than a hold on Medi-Cal eligibility. | No |
Practical Implications
For individuals, a 59 hold means their active enrollment might be disrupted, potentially affecting their access to services or benefits until the status is resolved. For administrative bodies or healthcare plans, it signifies that they will not receive funding for that individual during the hold period, necessitating a review and update of the recipient's changed information to reinstate enrollment and capitation.
Addressing a 59 hold typically involves:
- Verifying and updating the recipient's current personal data.
- Ensuring that any changes in residency or other coverage are correctly reflected in the system.
- Reactivating enrollment once the updated information is processed and verified.
