Can you have Medi-Cal, Medicare, Individual, Employer Group and OHC Other Health Insurance, at the same time?
how much does each one pay?
Which pays first?
Can you still pick which doctor and hospital you go to?

Can you have Private –  OHC Other Health Insurance &
Medi Cal at the Same time?

Yes,

You can have Medi-Cal even though you have Other Health Coverage (OHC) through individual or group private health (or dental) insurance coverage.

See the email we rec’d May 17th from Medi Cal to clarify some of these issues.

Which Insurance Plan pays #first
Medi-Cal or OHC Other Health Coverage?

Under federal law, your private health insurance must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including your other plans co-payments, co-insurance and deductibles.   See below about if you have a Medi Cal HMO.   Also, you may have a problem if you went to a provider that isn’t a Medi Cal doctor.   You may not quote this page.  It’s a summary of what we have footnoted and linked to from official documents & law.  Cite only those.

If you are in a HMO – Managed Care Providers  coordination may be difficult and/or you can’t get a Medi Cal HMO, but must have fee for service, see our FAQ’s and response from the Medi Cal Ombudsman for more details.

See the email we rec’d May 17th from Medi Cal to clarify some of these issues

If you don't #want Medi-Cal 

Can you buy private insurance?

If your income qualifies for Medi-Cal, you can buy Insurance coverage (FREE QUOTES), but there won't be ANY subsidies.  You pay the full premium.  However, if it's Share of Cost, it's not considered Minimum Essential Coverage, so you could get subsidies.  Get quote here.

 

Friendly Agent's Blog on how to have different plans for different members of the family.

Medi-Cal Managed Care HMO – Health Care Options 

#Pick your Plan

Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.

Medi Cal Provider HMO Selection Website

learn choose enroll medi cal plans

Learn more:

While you can have an employer or Indivudaul Plan and Medi Cal, there is However  a
#MANDATORY Medi Cal Managed Care – HMO health
Enrollment

One  must choose a  Managed Care – HMO health plan – provider within 30 days after enrollment in Medi-Cal otherwise the State will pick plan for you. Medi-Cal Website  Unless you have Other Health Coverage -OHC, then you must go Fee for Service.

When you have an HMO  managed health care, the State of California makes a deal  with health plans and pays a fixed amount each month per member enrolled in the plan – capitation.   The HMO health plan is then responsible for providing you  all your Medi-Cal services included under the EOC Evidence of Coverage.   HMO Plans are required under state and federal law to maintain an adequate Medi-Cal provider network to ensure that each member has a primary care physician and must report on quality and access measures.

#Clarification from Medi-Cal on
HMO Mandatory Enrollment and other coverage OHC

Hi Steve –
 
On May 8, you reached out to our Office of Communications, and requested answers to the following questions.  Please see DHCS’ responses*** below.
 
  1. What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?
  1. On this DHCS page, the public is told they must choose an HMO.  Nothing is said about if you have other coverage, it’s excluded. [not mentioned on the DHCS page?]
 
Medi-Cal managed care plans do not stop beneficiaries from enrolling in private health insurance plans.  If a Medi-Cal beneficiary is currently enrolled in a Medi-Cal managed care plan, and subsequently purchases private health insurance, they will not be disenrolled from the Medi-Cal managed care plan. 
 
The website above only applies to Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care plan, which is the large majority of the Medi-Cal population. 

 

 

 
 
  1. On or about 10.26.2020 the Medi Cal Ombudsman emailed and said that if one had private insurance they could NOT enroll in a Medi Cal Managed Care Plan!
 
If a Medi-Cal beneficiary has active other health coverage upon Medi-Cal enrollment, they are currently not eligible for enrollment into a managed care plan. 

 

 

 
However, Medi-Cal beneficiaries with other health insurance will be eligible to enroll in a managed care plan after DHCS implements the California Advancing and Innovating Medi-Cal (CalAIM) initiative to transition share of cost beneficiaries to Medi-Cal managed care for non-duals (Medi-Cal coverage only) on January 1, 2022 and duals (Medicare and Medi-Cal coverage) in January 1, 2023.
 
  1. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?
 
A Medi-Cal beneficiary who has other health insurance (OHC) is required to exhaust their OHC before Medi-Cal assumes payment for a service.  However, Medi-Cal providers are not allowed to deny a medically necessary service even if the provider has evidence that a beneficiary has OHC. In order for the provider to bill Medi-Cal for that service, the provider must first obtain a denial letter from the OHC entity.  (Other Health Coverage (OHC) Guidelines for Billing (other guide) (ca.gov) pg1)
 
  1. When a member uses HMO services, how does the HMO collect & bill other coverage?
 
Assuming that you are referring to “HMO” as a Medi-Cal managed care plan, the State has direct data exchanges with commercial health insurance carriers to identify members with other health coverage. This data is shared with Medi-Cal Managed Care Plans to ensure effective coordination of benefits. If other health coverage information is present at time of billing, the Medi-Cal managed care plan will reject (not deny) the claim and provide the other health coverage information to the provider for billing. If other health coverage information is obtained after a Medi-Cal managed care plan has paid for the claim, the plan will initiate post-payment recovery.
 
  1. When a member uses say his Employer’s HMO or PPO how does the  collect copays & deductibles  from Medi Cal HMO and/or fee for service?
 
Medi-Cal managed care plans and Medi-Cal fee-for-service do not pay for a Medi-Cal beneficiary’s copays or deductibles for their employer’s HMO/PPO plan. 
 

The DHCS Health Insurance Premium Payment program does offer an option for a narrow population of newly enrolled Medi-Cal beneficiaries to receive reimbursement for OHC co-pays and deductibles for a limited time, subject to eligibility requirements.  Please see dhcs.ca.gov for additional information.   

 

 

 

 
  1. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
    is CA using?
  1. How is this being enforced & implemented?
 

                 CA currently uses the two out of four approaches:

 

 

 

 
·  Enrollees with any other insurance coverage are excluded from enrollment in managed care (note that this will change after Cal AIM implementation)
· Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments
o This approach is used when a Medi-Cal beneficiary is first enrolled in a Medi-Cal managed care plan and subsequently obtains other health coverage. TPL responsibilities are then delegated to the Medi-Cal managed care plan for the first 12 months after the date of payment for a service.
 
If you have any additional questions on other health coverage and Medi-Cal, please let me know.
 
 
Thank you!
 
Lindsey Wilson, Chief
Coordination of Benefits and Administration
Third Party Liability and Recovery Division 
 
***Please note that a few things in the letter were changed, so that it would look better when posted on the web.
 
 
Contrast…
 

You cannot choose a medical HMO Managed Care plan if:

 

 

 

You are a member of a commercial medical plan through private insurance Health Care Options DHCA.Govresponse from the Medi Cal Ombudsman * Western Poverty Law Page 5.219Medicaid.gov *

You must take Fee for Service.

Request for exemption from enrollment in Managed Care Plan, but I don’t see OHC as a reason

IEHP Provider manual seems to imply their HMO will allow it?

See the email we rec’d May 17th from Medi Cal to clarify some of these issues

What is Medi Cal Fee for Service?

FFS Fee for Service

Under FFS Fee for Service, the California state pays enrolled Medi-Cal providers directly for covered services provided to Medi-Cal enrollees. It is the enrollee’s  responsibility to find a physician who accepts Medi-Cal. CHFS.org *

How much does Medi Cal pay?

Medi-Cal Fee for Service will pay the maximum that they are allowed to! 

Here’s information what Full Scope Medi Cal  * or see what the HMO’s Evidence of Coverage say, and Denti -Cal Cover. Of course Medi Cal  will deduct the payment amount, from your other health plan, if any.

Medi-Cal will not pay higher charges  of a provider’s bill when the provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as payment in full. See our webpage on negotiated rates.  The Medi-Cal provider must submit an Explanation of Benefits or denial letter from the OHC along with the Medi-Cal claim. If Medi-Cal later discovers OHC, Medi-Cal will bill the OHC for the Medi-Cal services.

If you have a Medi-Cal share of cost you must pay it before Medi-Cal will pay for your service.

For Medi Cal HMO’s check out each one’s summary of benefits and EOC’s Explanation of Benefits.

 

How do I find a provider that accepts Medi Cal?

Sorry there isn’t a  Fee For Service provider directory.  Try calling  Medi Cal @  1-800-541-5555. You may need to call providers to see if they accept FFS Medi-cal. Email from Ombudsman 1.26.2021 *

See the email we rec’d May 17th from Medi Cal to clarify some of these issues

 (HIPP) Health Insurance Premium Payment Program/Cost Avoidance

The Health Insurance Premium Payment (HIPP) program is a voluntary program for qualified beneficiaries with full scope Medi-Cal coverage. HIPP approved Medi-Cal eligible beneficiaries shall receive services that are unavailable from third party coverage and offered by Medi-Cal.  Learn More 

 

 

Covered CA Certified Agent

#Covered CA Certified Agent  

No extra charge for complementary assistance 

I'm in Sonia

 

Medi Cal Contact Information

#Email  Addresses & Phone #'s: 

Ombudsman

  • Ombudsman Webpage
    • Phone: 1-888-452-8609
    • Email:   [email protected] 
      • The Office of Ombudsman cannot approve/terminate/reinstate Medi-Cal eligibility; alter aid codes, change/update addresses, change/update name or initiate inter-county transfers.

Complex Questions Assistance

Medi-Cal for All Children program 

SB 75 Eligibility and [email protected]

Medi Cal - #County Office Lookup

See our Main Webpage on Medi Cal contact information

Specimen Policy #EOC with Definitions

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

Steve Explains how to read EOC

Videos by Steve Shorr

Our website is #MUCH more than just
Pro Bono helping you with Medi-Cal

We've developed the Medi-Cal portion of our website, as many of our Covered CA clients unfortunately end up here, if their income drops below 138% of FPL, Federal Poverty Level

We do not get a nickel, for this site or for helping people enroll in Medi-Cal, nor answering complex questions.  When you have other questions or need coverage, take a look at   our other websites:

Do you have to #tell or Report to Medi Cal that you have other coverage?

If you are a Medi-Cal beneficiary and have individual or group private health (or dental) insurance coverage, you are required by federal and state law to report it. You can report it directly to Department of Health Care Services (DHCS) by visiting their webpage on that.

You can also report it to your county eligibility worker, your health care provider, and/or to the Local Child Support Agency (LCSA), when there is an absent parent who may be responsible for your child(ren)’s medical care, or in establishing paternity of a child born out of wedlock. If you fail to report any private health insurance coverage that you have, you are committing a misdemeanor.

The State of California is mandated to find out if you have other health coverage or if it’s available  and to collect payment from liable third parties, like a car accident.  Thus, you must assign rights to medical support and help locate liable third parties, even going so far as to helping to establish paternity of children born outside of marriage so that the state may seek payment for medical services provided to the child.

What do I do if my other health plan sends a check to me?

Send any payment you get directly from an insurance carrier for services paid by Medi-Cal or medical support payment you get from the absent parent to DHCS at:

Department of Health Care Services
Third Party Liability and Recovery Division
Cost Avoidance Section
P.O. Box 997424, MS 4719
Sacramento, CA 95899-7424

If you have other health insurance coverage, the computer system will be coded to show other health insurance. If this information is incorrect you can contact your county eligibility worker to temporarily override this information.

Better yet you can report your other Insurance Information ONLINE!

If you are having a claims payment problem with a provider, you may call the Beneficiary and HIPAA Privacy Help Desk at (916) 636-1980.

If you have both Medicare and Medi-Cal, aka Medi Medi  Medicare (not Medi-Cal) will pay for most prescription drugs for Medi-Cal beneficiaries who are eligible for Medicare Part A (hospital) or Part B (outpatient). Here’s our webpage on Medicare Part D (drug coverageMedi-Cal What it Means to you”  Section 12 

Historical Medi Cal Provider Issues

54% of MD’s accept Medi-Cal  4.3.2015

Litigation on Medi-Cal violating Judges order and putting people into HMO’s, rather than fee for service. CA Health Line 8.10.2017

Number of Medi-Cal Providers down by 25% californiahealthline.org/2014/7/15

Paul Ryan – more and more MD’s just won’t take Medi-Cal – Medicaid Fact Checker Washington Post 2.1.2017

Video on problems finding doctors

Many large physician groups no longer contract with health plans serving adult Medi-Cal patients, saying that government reimbursements are too low to cover the cost of treating patients.

For the typical office visit, Medi-Cal pays doctors only about a third of what their peers at federally qualified health centers receive, $150 on average. If the health centers’ fees exceed what insurers will pay, their administrators can bill the state for the residual amount. So, the state is forced by federal law to pay more for office visits at federally qualified health centers than it would have paid physicians in private hospital groups. Sacramento Bee 10.2.2017

The U.S. Supreme Court’s ruling October 2014 that private health care providers cannot file lawsuits against state Medicaid agencies over low reimbursement rates could limit future Medi-Cal lawsuits, the Los Angeles Times‘ “PolitiCal” reports.  CA Health Line

Medi-Cal is California’s Medicaid program (Megerian, “PolitiCal,” Los Angeles Times, 3/31).

Los Angeles Times 8.14.2014 – Few Providers, etc

There are now about 11 million Medi-Cal beneficiaries, constituting nearly 30% of the state’s population

Under the Affordable Care Act, the federal government pays 100% of the costs for newly eligible Medi-Cal enrollees for the first three years. But the state is responsible for 50% of the costs for those who qualified for the program before the Obamacare expansion, even if they hadn’t previously enrolled

With payments of $18 to $24 a visit, “doctors can’t continue to accept new patients and keep their doors open,” said Molly Weedn, a spokeswoman for the California Medical Assn. Without enough doctors, Medi-Cal patients could continue landing in costly emergency rooms — the opposite of Obamacare’s aims.

There is application backlog of about 490,000 people,

California has already demonstrated to the rest of the country that it can dramatically cut its rate of uninsured, largely by increasing the size of Medi-Cal. Now it needs to show that its public insurance program can actually deliver the care its new enrollees are counting on. latimes.com

Money in CA budget to expand Medi-Cal but 10% reduction in payments to MD’s  california health line.org

Basic Law & Rules on #Coordination of Benefits

Benefits When You Have Coverage under More than One Plan

When Coordination of Benefits Applies

This coordination of benefits (COB) provision applies when a person has health care coverage under more than one Plan.

The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits.

The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses.

The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense.  §1300.67.13 *   UHC EOC

References & Links

More Explanations of #COB Coordination of Benefits

Technical Resources

  • Subrogation if you get in an accident and someone else can be sued
  • CA Insurance Code §10270.98  Group Health Insurance Co-Ordination of Benefits

How are claims paid if you have #Medicare &
Other Insurance?


Dual Coverage?

If you have questions about how Medicare works with other coverage, you’ve come to the right page.  Hopefully, we’ve or our links will answer all your questions on  dual coverage here.  If not, use the FAQs / Ask Us a Question feature below.

We’ve also included the relevant pamphlets from Medicare.

FAQ’s
I have Medicare and:

If you still have questions,  email us, * set a meeting, * ask us a question right on this page, you don’t have to even leave your name.

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

That's why the premium is very low or ZERO!

Medicare #DualCoverage
# 02179
 
 

Medicare Dual Coverage Pamphlet

Our Webpage on Medicare & Dual Coverage 

Coordination of benefits -
two or more insurance plans
VIDEO 

#Subrogation
Medicare's Right to collect from other Coverage

You're Medicare Advantage plan has  the right and responsibility to collect - subrogate  for covered Medicare services for which Medicare is not the primary payer.

According to CMS regulations at 42 CFR sections 422.108 and 423.462,    Anthem MediBlue Access (PPO), as a Medicare Advantage organization, will exercise the same rights of recovery  that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws.  Anthem MediBlue Access (PPO) Evidence of Coverage

Medicare Secondary Payer Recovery Process
Click to Enlarge 

Benefits Coordination & Recovery Center (BCRC)

The BENEFITS COORDINATION & RECOVERY CENTER (BCRC) acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determine whether the coverage pays before or after Medicare.

BCRC  acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary – the one that pays 1st. 

Cal Medi #Connect program

D SNP – Dual Eligible Special Needs Plans

Medi Medi – Medicare & Medi-Cal Plan (MMP – Dual Eligible)

Can you choose your own  Medicare Advantage Plan & Medi-Cal HMO or one will be chosen for  you?

Cal MediConnect Changes to D-SNP in 2023

On January 1, 2023, your Cal MediConnect (CMC) plan will change into matching Medicare and Medi-Cal plans provided by L.A. Care. We are the health plan providing your health care through your CMC plan now.

The matching plans are designed to coordinate care for people who have both Medicare and Medi-Cal. You will still get the same health care benefits. You will begin getting letters about this change in October 2022.

You will continue to get all your services through CMC until December 31, 2022. Then on January 1, 2023, you will automatically start getting services through your matching plans.

If you are in CMC today, you DO NOT need to do anything to enroll into the matching plans and keep your current benefits.

Your new plans will help you with all your health care needs and will continue to coordinate your benefits. This includes medical and home- and community-based services. It also includes medical supplies and medications. The matching plans will include the doctors you see today, or we will help you find a new doctor if you would like.

If you have additional questions about your coverage in 2022, please call us at 1.888.522.1298. Cal Medi Connect *

FAQ’s

  • Option A Medicare & Medi-Cal in ONE plan (Los Angeles Options)
  • Option B Keep Medicare (Get an Advantage Plan or Medi Gap?) and get a Medi-Cal Plan (Los Angeles) Cal Duals.org Cedars Sinai

Our website on Medicare Advantage Plans

My Care, My Choice 

 

My Care, My Choice helps people who have both Medicare and Medi-Cal explore health care coverage choices based on their location, their needs, and what they want from their coverage.

Unlike other websites, MyCareMyChoice.org isn’t run by a health plan or broker, and it doesn’t sell any products.  But it’s funded by SCAN.

Our goal is simple: helping Californians with Medicare + Medi-Cal learn about their coverage options so they can make the best choice based on their unique needs.

The Advisor Tools page is designed to help the advocates, family members, caregivers, and service providers who help people with Medicare and Medi-Cal make health care decisions.

Cal Optima Logo

Consumer Links

Some Cal Medi Medicare MMP Default Plans:

Technical Links

#Autism

  • I have an adult son with Asperger syndrome.
  • I am looking for information and assistance regarding his rights rights and resources he might be eligible for.
  • He is turning twenty-six in November.
  • They have ABA therapy with thousands of dollars of copay a month—straight medi-cal will not cover ABA therapy, but the managed care plan would.
  • Is it correct we cannot choose a managed care plan since we have the primary insurance for them?
  • Coordination of Benefits (COB): The process of determining which insurance coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment and payment responsibilities for members with more than one type of health insurance coverage
  • Fee-For-Service (FFS): This means you are not enrolled in a managed care health plan. Under FFS, your doctor must accept “straight” Medi-Cal and bill Medi-Cal directly for the services you got.
  • Enrollees with any other insurance coverage are excluded from enrollment in managed care
  • I’ll ask [email protected] if they can shed any light on this issue.
  • I don’t see that commercial insurance excludes one from enrolling in the Medi Cal HMO
  • Please note, I’m not an authorized Medi Cal representative and nothing I say changes any Medi Cal rules. On my soapbox, I’m upset that Covered CA expects us to facilitate enrollment, without compensation.
  • Here’s the reply excerpt from Medi-Cal, let me know if you want the full email. I’m just showing the NEW information, not what I already said above or the webpage above.
  • If you have specific questions about Medi-Cal Managed Care, please contact the Office of the Ombudsman by phone at 1-888-452-8609 or by email at [email protected]
  • Please keep in mind that only healthcare providers enrolled in Medi-Cal will be reimbursed by Medi-Cal for your care. The best way to ensure that you will not have to pay for your medical care is to ask your provider before your appointment if they accept Medi-Cal. If you already have a provider that you like, be sure to check to see if they are part of the provider network for any plan you select.
  • I already told you about the exemption request – please click on the link above. IMHO from what you’ve said, you are not eligible for an exemption.
  • Response from the Ombudsman
    • That is correct, having private insurance does block a Medi-Cal beneficiary from being enrolled in a Medi-Cal Managed Care Plan.
    • The information provided is correct.
    • Office of the Ombudsman 358
      Managed Care Operations Division
      Dept. of Health Care Services
      Phone: (888)452-8609
      Fax (916) 440-7438
      [email protected]
  • I’ve been told they must stay on FFS [Fee for Service] or straight medi-cal since they have primary, and cannot choose a managed care plan in our county (Alameda).
  • They have ABA therapy with thousands of dollars of copay a month—straight medi-cal will not cover ABA therapy, but the managed care plan would.
  • Is it correct we cannot choose a managed care plan since we have the primary insurance for them?
  • See the response from the Medi Cal Ombudsman below!
  • If you wanted to opt out of HMO enrollment, here’s the form
  • I don’t see why Medi Cal would not pay for ABA therapy. Mental Health is a mandated essential benefit.
  • Autism is listed as a “severe mental illness” under CA AB 88
  • Coordination of Benefits (COB): The process of determining which insurance coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment and payment responsibilities for members with more than one type of health insurance coverage
  • Fee-For-Service (FFS): This means you are not enrolled in a managed care health plan. Under FFS, your doctor must accept “straight” Medi-Cal and bill Medi-Cal directly for the services you got.
  • Enrollees with any other insurance coverage are excluded from enrollment in managed care
  • I’ll ask [email protected] if they can shed any light on this issue.
  • I don’t see that commercial insurance excludes one from enrolling in the Medi Cal HMO
  • Please note, I’m not an authorized Medi Cal representative and nothing I say changes any Medi Cal rules. On my soapbox, I’m upset that Covered CA expects us to facilitate enrollment, without compensation.
  • Here’s the reply excerpt from Medi-Cal, let me know if you want the full email. I’m just showing the NEW information, not what I already said above or the webpage above.
  • If you have specific questions about Medi-Cal Managed Care, please contact the Office of the Ombudsman by phone at 1-888-452-8609 or by email at [email protected]
  • Please keep in mind that only healthcare providers enrolled in Medi-Cal will be reimbursed by Medi-Cal for your care. The best way to ensure that you will not have to pay for your medical care is to ask your provider before your appointment if they accept Medi-Cal. If you already have a provider that you like, be sure to check to see if they are part of the provider network for any plan you select.
  • I already told you about the exemption request – please click on the link above. IMHO from what you’ve said, you are not eligible for an exemption.
  • I will check with the Ombudsman.
    • Response from the Ombudsman  That is correct, having private insurance does block a Medi-Cal beneficiary from being enrolled in a Medi-Cal Managed Care Plan.
    • The information provided is correct.
    • Office of the Ombudsman 358
      Managed Care Operations Division
      Dept. of Health Care Services
      Phone: (888)452-8609
      Fax (916) 440-7438
      [email protected]
  • I have two kids with autism who qualified for Medi-Cal with the Regional Center income waiver program.
  • I enrolled them in one of the Medical [sic] managed care plan and when I tried to use the plan for my kids ABA therapy it was denied.
  • I called Medi-Cal managed care health care options and they told me my kids can only have straight medical.
  • The problem I run into now is that I cannot find a provider who takes straight Medical.[sic] They will only take medi-cal managed care plans.
  • I have to pay $7,000 in co-payments with my private insurance before any therapies or services are free.
  • Also, I know that there are other families who have private insurance and are also enrolled in the managed care plan.
  • My question is how can I get enrolled again so they can cover my co-pays? Do I have any other option?
  • We cannot afford $7000 in co-payments every year.
  • Thank you for any advice.
  • LEGISLATIVE COUNSEL’S DIGEST
    • Existing law …Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines behavioral health treatment” to mean specified services provided by, among others, a qualified autism service professional supervised and employed by a qualified autism service provider. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
    • The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
    • The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional.
    • The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
    • The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services.   leginfo.ca.gov *
  • Court Ruling in favor of autism –  AB 1704
  • VIDEO KCAL 9 Los Angeles – CA Appeals Court Rules Public Insurance Must Cover Autism Treatment
  • Links & Resources
  • We’re a provider for ABA Applied Behavior Analysis services only (not a medical facility).
  • A client has Medi-Cal as their secondary insurance and would like us to bill Medi-Cal; however, we are not contracted with Medi-Cal as of yet (we our contracted with Molina). So I have a couple of questions:
    • 1. Can I still bill Medi-Cal for services already rendered?
      2. Can the parent submit receipts to Medi-Cal for paid services on their own behalf for reimbursement?
      3. Is there a phone number of someone I can contact directly to help with questions such as these?

CHCF California Health Policy Survey 

chcf California health policy survey

  • 1/2 of California's skipped health care in the past year, due to cost
  • 1/4 themselves or knew someone who had problems paying a bill
  • 1/5 had someone close to them experience homelessness
  • 1/2 have used telehealth - phone or video 
  • 6 in 10 think there is racial or ethnic disparity

11 comments on “Dual Coverage? Medi Cal, Employer Group, Individual, Cal Medi Connect & Medicare

  1. I have Medi-cal.

    I may get a w2 job that pays for medical insurance. I want to keep my Medi-cal insurance however as I get very expensive immune therapy monthly and I do not want to change providers

  2. I am debating on whether to sign up for UCSHIP at Berkeley or to opt-out.

    I am also on my parents’ Medi-Cal with Kaiser through LA Care and HealthNet Dental.

    1. Can I have both insurances at the same time or will I get dropped from Medi-Cal?

    I know when I am on campus I should go to the University Health Services facility for care.

    However I’m a little confused about where I should go when I am back home.

    2. Can I still go to the usual Kaiser facility and HealthNet Dental Provider?

    I don’t want my parents to to get a huge bill when I get treatment at home.

    How would the insurance work?

    Please help. Thank-you in advance!

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