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.
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.
- 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.
#My Medi-Cal
How to get the Health Care
You Need
24 pages
Smart Phones - try turning sideways to view pdf better
- Medi Cal Explained CHCF
- More explanation
- California Advancing and Innovating Medi-Cal (CalAIM) is a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory.
- Medi Cal Contact Information
- Our Webpages on
- Medi Cal Benefits
- Denti Cal
- Medi-Cal – MAGI Income Eligibility Criteria
-
BIC Benefits Identification Card
Medi-Cal Managed Care HMO – Health Care Options
Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.
Learn more:
- Disability Rights.org –
- What are Medi Cal Managed Care Plans? What do I need to know?
- Medi-Cal Managed Care Health Plan Directory
- Poor Care Co-Ordination? New contracting process Deficient Oversight CA Health Line *
- Disability Rights – Medi Cal provider HMO’s, what are they? What do I need to know about them?
- Medi-Cal Managed Care – Health Care Options
- EOC’s, Forms & Income Charts from Insure Me Kevin.com
- Medi-Cal Managed Care Provider Search
- Sacramento? dhcs.ca.gov//mmcd health plan dir
- Exemption from enrolling in a Health Care Plan
- health care options.dhcs.ca.gov
- health care options.dhcs.ca.gov/Med Exemption WEB
- You May Get A Medical Exemption If:
- • You have a complex medical condition; AND
• The care you get from your Regular Medi-Cal doctor for the complex medical condition
cannot be changed, because your condition could get worse; AND
• Your Regular Medi-Cal doctor is NOT part of a plan in your county. You may see
more than one Regular Medi-Cal doctor. If you do, have the form filled out by the
doctor who sees you most often. Ask your Regular Medi-Cal doctor if he or she is part
of a Plan in your county. This should be done before you submit this form.
- • You have a complex medical condition; AND
- You May Get A Medical Exemption If:
- Provider Search – Statewide Fee for Service
- See our webpage on IMR Independent Medical Review
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.
- Medi Cal Managed Care Find a Provider
- See the email we rec’d May 17th from Medi Cal to clarify some of these issues
- chcf.org/primary-care-matters * More readable summary * Health care systems with strong levels of primary care investment have better and more equitable health outcomes, lower care costs, and better care quality. We can build a healthier future for all Californians by focusing resources back to patients and their relationship with primary care providers.
#Clarification from Medi-Cal on
HMO Mandatory Enrollment and other coverage OHC
- What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?
- 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?]
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.
- 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.
- When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?
- When a member uses HMO services, how does the HMO collect & bill other coverage?
- 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?
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.
- Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
is CA using?
- How is this being enforced & implemented?
CA currently uses the two out of four approaches:
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.Gov * response from the Medi Cal Ombudsman * Western Poverty Law Page 5.219 * Medicaid.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
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!!!
- 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]
- Office of the Ombudsman 358
- That is correct, having private insurance does block a Medi-Cal beneficiary from being enrolled in a Medi-Cal Managed Care Plan.
#Covered CA Certified Agent
No extra charge for complementary assistance
- Appoint us as your broker
- 17 Reasons to appoint us as your agent - broker
- Set Consultation Meeting via Phone, Skype or Zoom
- VIDEO on ARPA Stimulus and more Covered CA Subsidies
- Videos on how great agents are
Medi Cal Contact Information
- Medi Cal Contact Sheet
- [email protected] regarding general Medi-Cal eligibility. If the question contains specific details the county or the district office that handles your case must answer.
- Medi-Cal Member & Provider helpline, at (800) 541-5555.
- California Department of Health Care Services 1-844-253-0883
- [email protected]
- Non MAGI Medi Cal 1.916.345.8675
- [email protected] Ms. Leslie Benson
- IHSS In Home Supportive Services
- Direct Phone # for Medi Cal 866.613.3777 (Anthem Blue Cross?)
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
- Health Consumer Alliance at 1-888-804-3536.
- Disability Rights California at 1-800-776-5746.
- Covered CA Facebook Page
- HICAP – Health Insurance Counseling & Advocacy Program
- CA Health Care Advocates – 1-800-434-0222 Volunteer counselors can help you understand your specific rights and health care options
- Medi Cal Consulting Services
- National Center on Law & Elder Rights - Case Consultation for Professionals
- VITA Volunteers Income Tax Assistance
- Medi Cal - Technical Comprehensive Reference Materials
- Our webpage on education, research & tutoring for a fee
- aging.ca.gov/Medicare_& Medi Cal Counseling
- Elder Care locator
- medi helper.com
- Pdf Brochure - I was told their fee is $3k
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
Term Life Quote #naaipquote
- Set up Schedule a phone, skype or face to face consultation
- Tools – Calculator to help you figure out how much you should get
Life Insurance Buyers Guide
How much life insurance you really need?
- Life Screening Form Detailed NAAIP
- Please complete & return and we’ll search and consult for you.
- Short ONE page form – CPS
- Set up a phone, Zoom, skype or face to face consultation
Specimen Individual Policy #EOC with Definitions
Employer Group Sample Policy
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!
- Find your own Individual EOC Evidence of Coverage
- It' important to use YOUR EOC not just stuff in general!
- Obligation to READ your EOC
- Plain Meaning Rule - Plain Writing Act
- Our Webpage on Evidence of Coverage
- OOP Out of Pocket Maximum - Many definitions are explained there.
VIDEO Steve Explains how to read EOC
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.
- See our webpage on
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
#Report changes as they happen - within 30 days! 10 CCR California Code of Regulations § 6496
10 days for Medi Cal 22 CCR § 50185
Our webpage on ARPA & Unemployment Benefits - Silver 94
IRS Form 5152 - Report Changes
- Our VIDEO on how to report changes to Covered CA
- Lost your job? How to keep your Health Insurance. Shelter at Home VIDEO
- References & Links
- Here's instructions, job aid, reporting change in income
- Our webpage on the exact definition of MAGI Income
- If you've appointed us - instructions - as your broker, no extra charge, we can do it for you.
- Voter Registration
- Task Guide Phone - Voter Registration
- Denial of benefits and possible criminal charges if you don't report changes in income!
- Fudging Income?
- Western Poverty Law on reporting changes
- How to cancel coverage.
- Visit our webpage on how to report changes
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
Guide to #Contract Interpretation
- Read the Statute – Policy
- Read the Statute – Policy
- Read the Statute – Policy
- Then when you think you understand it, read it again
- Plain Language Video
- Tools to Read a Statute VIDEO
- Contract Interpretation in California: Plain Meaning, Parol Evidence and Use of the Just Result Principle
Our webpage on
- jiggery pokery and contract interpretation
- Evidence of Coverage EOC
- Plain Meaning Rule - How to read Policy - Contract
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.
#Understanding Medicare Advantage Plans (PDF) #12026
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!
- Set a phone or Skype Meeting
- #Intake Form - We can better prepare for the meeting
- HMO - Narrow Networks?
- Do I just sign up with a Medicare Advantage Company and automatically get * Parts A & B or do I have to get those from Medicare.Gov * VIDEO
- Get Quotes, Full Information and Enroll
- MANDATED wording!: Think Advisor * ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’
- We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!
- FYI a 4.27.2022 HHS Office of the Inspector General report found that MAPD plans denied 13% of prior authorizations that would have been covered under original Medicare (Conversely, Medi Gap, just follows what Medicare pays.)
- 88% of MAPD enrollees are happy
-
MAPD plans often include Dental & Part D - Rx Prescriptions and often have NO premiums! How is that possible? The Federal Government pays them around $700/month to handle your medical care. You must continue to pay your Medicare Part B premium of about $170/month. It's best to apply when you turn 65 for the supplement plans or advantage plans, as that's the main "Open Enrollment" period, guaranteed issue for any plan.
-
Medicare Advantage Plans also have an annual open enrollment now known as AEP Annual Election Period October 7 to December 15th.
-
Additional Coverage is important as Medical Bills are increasing Seniors Credit Card Debt or leading to possible bankruptcy?
Medicare #DualCoverage
# 02179
Our Webpage on Medicare & Dual Coverage
Coordination of benefits -
two or more insurance plans
VIDEO
- Medicare.Gov on how Medicare works with other insurance.
- Employer obligation to report # of employees to Medicare
- Explanation from Cal Broker Magazine Sept 2019
- Sample Small Employer Group Health Plan
#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 *
- 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.
Consumer Links
Some Cal Medi Medicare MMP Default Plans:
- CalDuals is a website to support California’s Dual Eligible Population. Here you will find information about Medicare and Medi-Cal integration through the Coordinated Care Initiative, or CCI. The CCI was launched by the state of California to provide better coordinated care to people with both Medicare and Medi-Cal – dual eligibles.
- Health Net
- Blue Cross
- A Primer on Dual-Eligible Californians: How People Enrolled in Both Medicare and Medi-Cal Receive Their Care Chcf.org
- cms.gov/MMP Marketing Information and Resources
- Cedars Sinai Tool & Information – How to OPT OUT! Also applies EVEN if you don’t use their facilities!
- dhcs.ca.gov Technical Page on Cal Medi-Connect Demonstration
- Health Care Options 844.580.7272 – State Enrollment Broker – Enroll & Dis-enroll
- HICAP – CA Health Care Advocates – 1-800-434-0222
- Los Angeles Times 2.1.2015 Problems with shifting care for costly patients
- DHCS.Gov Medi-Cal Managed Care
- ca health advocates.org (Medi-Cal)
- LIS – Low Income Subsidy (Medicare Part D Rx – Help with Drug Costs)
- Doctor’s can’t bill Medi Medi patients for Co Pays, Deductibles, etc.
- InsureMeKevin.com on Blue Cross SNP & Dual Eligibility with Medi-Cal
- Fraud, Waste & Abuse
- Justice in Aging duals demo advocacy.org/
- DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID (Medi Cal) MLN Knowledge Booklet
Technical Links
- SB 1008 and SB 1036
- CMS Reporting Requirements and other technical stuff
- Dual Eligible Performance Studies – Inovalon
- Problems with Medi-Medi – unwitting Guinea Pigs real clear policy.com
Other pages in Medicare Advantage Section
#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:
- 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
- EditApplied 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
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- 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
- Our web pages on
- 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?
- 1. Can I still bill Medi-Cal for services already rendered?
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
Cal Medi Connect
Guide Book
Primer on Dual Eligible – Those on Medi-Cal & Medicare
CMS on people dually eligible for Medi Cal & Medicare
BROKER ONLY
Guide to Dual Eligible Special Needs Plan 2021
I have Original Medicare A & B, start date 10-01-22 and ffs Fee for Service Medi-Cal .
Now being told by HealthcareOptions.dhcs.ca.gov, that It is mandatory that I join a Medi-cal Managed care plan.
My question is, how is this not a conflict of interest to join Managed Care when I enrolled in Original Medicare in order to see my Doctors at Cedar Sinai Medical Center who do not belong to Managed care.
We are updating this webpage now, to make it easier to find the sections on dual coverage, fee for service, etc. Check out our Medicare Advantage Plans
Blue Cross
UHP AARP
Blue Shield
that Cedars does accept.
https://www.dhcs.ca.gov/services/Pages/Medi-Medi-Outreach.aspx
https://atiadvisory.com/fixing-the-fide-snp-redefining-fully-integrated/
https://www.healthaffairs.org/content/forefront/congress-considers-strategies-improve-medicare-and-medicaid-integration-dual-eligible
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf
Can child qualify for medi-cal with one parent, when the other parent in a different household has private/ employer insurance for the child
Here’s the household size chart
I don’t find anywhere that having an employer group plan would disqualify you from Medi Cal.
The group plan would pay first, though.
Go ahead and apply, see what happens. Ask any further questions from someone who gets paid or has grant $$$ to help you.
https://www.dhcs.ca.gov/provgovpart/Documents/Duals/DSNP-Feasibility-Study.pdf
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
Have you verified what providers are available to you from your Employer’s Coverage?
Did you ask your providers what Insurance’s they accept?
Might you still qualify for Medi Cal even if you have a job? See the income chart
We are not compensated to help people with Medi Cal. Here’s Medi Cal’s #’s
Might you qualify under Continuity of Care AB 369? We could research and give you the tools to advocate that for you for a fee. See also our webpage on appeals & grievances.
Kaiser unfairly getting lucrative no bid contract to to Medi Cal for everyone…
https://californiahealthline.org/news/article/california-medicaid-kaiser-permanente-newsom-deal-opposition/
https://capitolweekly.net/local-health-care-delivery-key-to-kaiser-medi-cal-contract/
I currently have medi-cal. But I might be able to also get employer insurance soon if all goes well but I will still be under the bracket of income level [138% Federal Poverty Level]
so I’m wondering am I able to have/keep medi cal and get employer insurance and have both or
Is it better to just keep medi-cal on its own instead?
Same with dental and vision etc.
I don’t see any reason why you can’t keep both.
Please re-read the webpage above as to how dual coverage works and what might be “better.”
We don’t get a nickel in compensation to help people with Medi Cal. If the above webpage doesn’t answer your question about “better” you can wait on terminal hold for Medi Cal Contacts & Social Service Agencies or the Medi Cal HMO you are with.
We can give you private tutoring, education & research for a nominal fee. However, we don’t give advice or recommendations.
A frustrating system for many on Medi-Cal
With subcontractors or sub-subcontractors, it can be hard to know where to turn for care
https://edition.pagesuite.com/popovers/dynamic_article_popover.aspx?guid=534437bf-4295-4d06-81c7-fb33e476c8c0&v=sdk
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!
We are not Medi Cal representatives nor do we get any compensation or support to help you.
1. Please re-read our webpage above. It’s all about having Medi Cal and other coverage OHC. The other coverage pays first. See the letter we got from Medi Cal explaining some of the more common FAQ’s we’ve come across.
2. I don’t see any reason you can’t go to Kaiser. Just be sure to report to Medi Cal that you have other coveage.
See above contact information for Kaiser & Medi Cal. Check with them.
View MORE FAQ’s
from December 2021 through December 2017
Hi Steve!
Thank-you so much for taking the time to answer my questions!
I was reading through other people’s questions and there was one dated May 11, 2021 where you mentioned that “There may be a problem if he likes his Medi Cal HMO as he would need to change to fee for service, when he has other coverage.”
Could you please clarify this?
I have Medi-Cal with Kaiser through LA Care.
Would I need to change to Fee for Service?
Please review the Q & A that we received from a Big Wig at Medi Cal in response to our inquiry of May 8.
We do not give advice or recommendations for Insurance Plans that we are not licensed and compensated for. This page is for reference and education only.
If you have further questions, please contact Medi Cal, the relevant Insurance Company or one of the consumer help groups.