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

Jump to section on:

• Introductory Brochure to Medi Cal 
• Reference Materials
• Mandate to report other coverage
• Cal Medi Connect – Medi Medi

• Which Pays first Medi Cal or other coverage?
• Can you get Private Coverage? 
• Basic Law on Coordination of benefits 

• FAQ & Clarification of Mandatory HMO Enrollment
• Choose HMO Plan
• Medicare 

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.

Please note that the Private Plan pays first and Medi Cal won't pay if the doctor isn't a Medi Cal provider.   Since Medi Cal is virtually HMO that might be difficult to have both plans pay.  

  Get quote here.

• FAQ's
  • Which Pays first Medi Cal or other coverage?
  • Choose HMO Plan
  • FAQ & Clarification of Mandatory HMO Enrollment
  • Friendly Agent's Blog on how to have different plans for different members of the family.

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

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?]

2. 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!

2. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?

3. When a member uses HMO services, how does the HMO collect & bill other coverage?

4. 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?

5. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
   is CA using?

1. How is this being enforced & implemented?

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 

How to stay in Fee for Service or Apply for Fee for Service considering the mandatory enrollment in HMO Managed Care?

FFS Fee for Service FAQ’s

• Are you prohibited from getting  a Medi Cal HMO managed care plan if you have other coverage?
  • See the response from the Medi Cal Ombudsman below!
  • Contrast that with the more recent reply from Medi Cal here!!!
    • If you wanted to opt out of HMO enrollment, here’s the form
• Definitions:
  • 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.
• 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.
• 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.
• 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.
    • Office of the Ombudsman 358
      Managed Care Operations Division
      Dept. of Health Care Services
      Phone: (888)452-8609
      Fax (916) 440-7438
      [email protected]

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:

• Employer Group Health Plans,
• Life Insurance 
• Disability, Pay Check Protection
• Long Term – Home Health Care,
• Medicare,
• travel
• Individual & Family Health Insurance
  • Tax & MAGI Income - Covered CA subsidies
• VIDEO tour

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.

• See our webpage on
  • child support  and
    •  Health Insurance Court Orders.
  • Medi Cal Webpage to report other coverage

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 coverage)  ^{“Medi-Cal What it Means to you”  Section 12} 

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

• model laws 50 pages drafted by the National Association of Insurance Commissioners (NAIC)
• Simple explanation of how Co Ordination of benefits works – Financial Web
• Illinois.gov – Simple Explanation with charts
• VIDEO Coordination of Benefits for Group Plan Members
• See the email we rec’d May 17th from Medi Cal to clarify some of these issues
• Our FAQ on Dental Coordination of Benefits

More Explanations of #COB Coordination of Benefits

• Delta Dentals Explanation
• “Working Spouse Rule”
• Health Care Reform Dependent Coverage vs Spousal Coverage
• How about an HSA (Health Savings Account) rather than buying extra policies?
• Supplemental Plans, like Colonial & AFLAC
• There might be some cases where a COB provision is not allowed – like HIPAA policies for when COBRA ends.
• Individual Plans cannot  have this clause per CCR California Code of Regulations 1300.67.13 BUT, they might require that you cancel other coverage.  ^{Blue Cross EOC Page 5}
  
• With COBRA protections and HIPAA availability when you lose Group Insurance, it probably is no longer necessary to keep an individual plan, “just in case.”  The extra premium, would probably be better spent on Life or Disability Insurance.
• Life Insurance does not have a co-ordination of benefits clause.  They will ask on the application though if you have other coverage to prevent over insurance and to make sure there is insurable interest.
• See also Balance Billing
  What if your doctor charges more than the negotiated rate?
• Employer Dental & Individual Dental? 

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.

• Medicare Guide to Dual Coverage who pays first publication  # 02179
• Medicare website,
• Medicare’s Subrogation Right to collect from other insurance

FAQ’s
I have Medicare and:

• I have Medicaid.
• I’m 65 or older and have group health plan coverage based on my current employment (or the current employment of a spouse of any age), and my employer has 20 or more employees.
• I’m under 65, entitled to Medicare because I have a disability (other than ESRD), I’m covered by a large group health plan because I or a family member is still working.
• I work for a small company that has a group health plan.
• I have a domestic partner with group health insurance coverage.
• I have declined or dropped employer-offered coverage.
• I’m retired, 65 or older and have group health plan coverage from my former employer.
• I’m retired, under 65 and disabled (other than by ESRD), and have group health plan coverage from my former employer.
• I have COBRA continuation coverage.
• I’m in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first. Who pays first if I go outside the employer plan’s network?
• I get health care services from the Indian Health Service.
• I have more than one other type of insurance or coverage.
• I have TRICARE.
• I have Veterans’ benefits
• I have ESRD and group health plan coverage.
• I have coverage under the Federal Black Lung Program.
• I have a claim for no-fault or liability insurance.
• I filed a workers’ compensation claim.

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.

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

• Blue Cross
• United Health Care
• Blue Shield

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.

View MORE FAQ’s

from December 2021 through December 2017 

#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.
  • Health Insurance:
    • Stay on Parents Health Plan
    • Medi Cal
    • ACA/Obamacare – needs say $18k income and can get subsidies
  • Treatment
    • Mental Health Parity – must cover same as any other illness
    • Applied Behavior Analysis
    • Mental Health Resources
  • Resources
    • Autism Speaks
    • Regional Center https://www.dds.ca.gov/ I’m out of country on vacation and can’t verify this link…
    • Mental Health – Probate Conservatorship
    • Autism Guide for Adults who have or might think they have Autism
    • Autism Resource Center – Magellan
• 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.
• .
  • Autism  Guide  for Adults who have or might think they have Autism
  • Guide for School Age Children
  • Our Webpages on SSDI  *  SSI * Medi-Cal *
  • How learning disabilities affect reading 35 pages from Reading Horizons
  • Hebrew Movie about an autistic young man whose father didn’t want him to move to a group home, despite what the Mother and Social Workers wanted… mk2films.com/film/here-we-are/
  • autism speaks.org/what-autism
  • nimh.nih.gov/autism-spectrum-disorders-asd
  • Trump signs $1.8 billion autism funding bill
  • President Donald Trump signed the Autism Collaboration, Accountability, Research, Education and Support Act (CARES) into law October 2019, which allocates $1.8 billion in funding over the next five years to help people with autism spectrum disorder and their families.
  • ABC News VIDEO
  • April 20, 2021 at 6:04 AMEditApplied Behavior Analysis ABA
    Autism Speaks Website
  • ABA has to do with understanding behavior and how it is affected by the environment. “behavior” refers to actions and skills.   “Environment” includes any influence – physical or social – that might change or be changed by one’s behavior.
  • VIDEO Introduction to  (ABA)  Applied Behavior Analysis treatment
  • Aetna’s Applied Behavior Analysis Medical Necessity Assessment Guide
  • Our webpage on Medical Necessity
  • Autism Parenting Magazine  ***   9 pages on ABA Therapy
  • href=”https://individuals.healthreformquotes.com/wp-admin/comment.php?action=editcomment&c=109798″ data-wpel-link=”internal”>Edit
  • AB-1074  pervasive developmental disorder or autism
  • This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment.
• 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
  •     Applied Behavior Analysis treatment
• VIDEO KCAL 9 Los Angeles – CA Appeals Court Rules Public Insurance Must Cover Autism Treatment
• Links & Resources
  • Our web pages on
    • Mental Health – An Essential Benefit
    • CA Mental Health Parity AB 88 (1999)
    • Federal Parity
    • Medi Cal and your own coverage – dual coverage
    • AutismSpeaks.org
    • friendship foundation.com  Redondo Beach
    • Facebook Page
    • facebook.com/OurTism/
    • Disabled children can stay on parents insurance beyond age 26
    • SSI Supplemental Security Benefits
    • Appeal or File Grievance with Health Insurance
    • What Insurance Companies have what Providers in their Network?
    • Autism Speaks – Types of Health Plans
    • CHIP Children’s Health Plan
    • Provider – Doctor & Hospital Finder
    • Hospital and Provider Sites showing Insurances Accepted
    • Instructions – Which Plan to find providers?
    • Medi-Cal
    • Medicare
      • Our webpage on when services & treatment are considered  Medically  Necessary
      • Clinical UM – Utilization Management Guidelines
      • CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
      • Autism Spectrum Disorders and Rett Syndrome – Clinical Guideline  UM
• 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 

• 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

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