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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?

Earning too much for Medi-Cal??? Get Covered CA Quote here

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.
    • Read the rest of the page on which plan pays first, etc.  namely, the other plan.
    • If you qualify for Medi Cal, you cannot get Covered CA Subsidies.

Earning too much for Medi-Cal??? Get Covered CA Quote here

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

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Earning too much for Medi-Cal??? Get Covered CA Quote here

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.

 

Long Term Care Information - Private, Medicare & Medi-Cal?

Jump to section on:

#My Medi-Cal 
How to get the Health Care
You Need
24 pages

Smart Phones - try turning sideways to view pdf better
My medi cal explanation of medi cal

 

Get much more detail on Medi Cal

Pick Medi Cal HMO Provider 

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:

Earning too much for Medi-Cal??? Get Covered CA Quote here

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.

Ask us a Question? FAQ's?

#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.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?

  • EHP .org/manuals Medi-Cal
  • 20 – Claims Processing (PDF)

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

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Specimen Individual Policy #EOC with Definitions

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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!

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Medi Cal - Main Page

Medi Cal  Fee for Service 

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?
  • 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]

Report other Coverage 

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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.

Long Term Care Information - Private, Medicare & Medi-Cal?
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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 

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Steve Shorr
Website Video #Introduction

Steve Video's

#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 

report income changes

IRS Form 5152 - Report Changes

report changes as they happen

#Autism

See our new webpage on Autism

Basic Law on Coordination of Benefits

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

Long Term Care Information - Private, Medicare & Medi-Cal?
Ask us a Question? FAQ's?

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

Blue Shield

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Summary of Benefits & Evidence of Coverage

Individual & Family Documents EOC SBC

Dental 

FAQ’s 

#Dentala Co Ordination of Benefits

 

  • Delta Dental – COB Co-Ordination of Benefits only on Group Policies
  • Denti – Medi Cal and other dental plans   Denti Cal Member Handbook
  •  
  • Question   I have an employer group dental plan with Walmart that only coordinates with other group plans.
    • I’m interested in a Individual Delta Dental PPO.
    • What does their co-ordination of benefits say?
      .
  • Answer I don’t see a co-ordination of benefits clause in the INDIVIDUAL Delta Dental disclosure
    • The disclosure you sent me, says your Walmart Group Plan only coordinates with other GROUP plans.
    • The definition of a “Plan” within the COB provision of group contracts enumerates the types of coverage which the Plan may consider in determining whether other coverage exists with respect to a specific claim. The definition:
    • Some Delta Dental groups that are not subject to the provisions of California Health and Safety Code §1374.19 have a non-duplication of benefits clause in their contract.
    • Such clauses means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.
    • For example, if both the primary and secondary carrier pay for the service at 80 percent level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50 percent of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80 percent – $50 = $14).
    • Dual coverage saves money for you and your group by sharing the total cost of dental benefits between two carriers. Containing costs is an important part of Delta Dental’s plan to keep you smiling.
    • understanding non duplication
    • Nonduplication COB – In the case of nonduplication COB, if the primary carrier paid the same or more than what the secondary carrier would have paid if it had been primary, then the secondary carrier is not responsible for any payment at all. ADA.org
      • Columbus.Gov

    • How does dual coverage and COB work?

      • With non-duplication of benefits, the primary carrier pays its portion first and the secondary carrier, instead of paying the remainder, calculates what it would have paid if it were the primary carrier and subtracts what the other plan paid.
      • For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. However, in the same scenario, if the primary carrier paid 50 percent, the secondary carrier would pay up to 30 percent. Dental Dental

      • §1374.19.   

        • (a)  This section shall only apply to a health care service plan covering dental services or a specialized health care service plan contract covering dental service pursuant to this chapter.

        • (b) For purposes of this section, the following terms have the following meanings:

          • (1) “Coordination of benefits” means the method by which a health care service plan covering dental services or a specialized health care service plan contract, covering dental services, and one or more other health care service plans, specialized health care service plans, or disability insurers, covering dental services, pay their respective reimbursements for dental benefits when an enrollee is covered by multiple health care service plans or specialized health care services plan contracts, or a combination thereof, or a combination of health care service plans or specialized health care service plan contracts and disability insurers.

          • (2) “Primary dental benefit plan” means a health care service plan or specialized health care service plan contract regulated pursuant to this chapter or a dental insurance policy issued by a disability insurer regulated pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code that provides an enrollee or insured with primary dental coverage.

          • (3) “Secondary dental benefit plan” means a health care service plan or specialized health care service plan contract regulated pursuant to this chapter or a dental insurance policy issued by a disability insurer regulated pursuant to Part 2 (commencing with Section 10110) of Division 2 of the Insurance Code that provides an enrollee or insured with secondary dental coverage.

        • (c) A health care service plan covering dental services or a specialized health care service plan issuing a specialized health care service plan contract covering dental services shall declare its coordination of benefits policy prominently in its evidence of coverage or contract with both enrollee and subscriber.

        • (d) When a primary dental benefit plan is coordinating its benefits with one or more secondary dental benefits plans, it shall pay the maximum amount required by its contract with the enrollee or subscriber.

        • (e) A health care service plan covering dental services or a specialized health care service plan contract covering dental services, when acting as a secondary dental benefit plan, shall pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage, or the enrollee’s total out-of-pocket cost payable under the primary dental benefit plan for benefits covered under the secondary plan.

        • (f) Nothing in this section is intended to conflict with or modify the way in which a health care service plan covering dental services or a specialized health care service plan covering dental services determines which dental benefit plan is primary and which is secondary in coordinating benefits with another plan or insurer pursuant to existing state law or regulation.

        • Since you said that when you called Walmart’s HR department and you state they told you something different, I googled and found more recent information on their website!

          • IF YOU HAVE COVERAGE UNDER MORE THAN ONE DENTAL PLAN
          • If you or a family member have coverage under the dental plan and are also covered under another dental plan (for example, your spouse/partner’s company plan), coordination of benefits may apply. The dental plan has the right to coordinate with other plans you are covered under so the total dental benefits payable will not exceed the level of benefits otherwise payable under the dental plan.
          • Coordination of benefits procedures and plans referred to as “other plans” are described in
          • If you have coverage under more than one medical plan in The medical plan chapter page 89
          • If you have coverage under more than one medical plan
            • The AMP [associates medical plan] has the right to coordinate with other plans under which you are covered so the total medical benefits payable do not exceed the level of benefits otherwise payable under the AMP. “Other plans” refers to the following types of medical and health care coverage:
            • • Coverage under a governmental program provided or required by statute, including no-fault coverage to the extent required in policies or contracts by a motor vehicle insurance statute or similar legislation
            • • Group insurance or other coverage for a group of individuals, including coverage under another employer plan or student coverage obtained through an educational institution
          • • Any coverage under labor-management trusteed plans, union welfare plans, employer organization plans, or employee benefit organization plans
          • • Any coverage under governmental plans, such as Medicare or TRICARE, but not including a state plan under Medicaid or any governmental plan when, by law, its benefits are secondary to those of any private insurance, nongovernmental program, and
          • • Any private or association policy or plan of medical expense reimbursement that is group or individual rated.
          • So, how would coverage for Crowns work?
          • Walmart Plan
          • MAJOR CARE
          • After you meet the annual deductible, the Plan pays 50% of the maximum plan allowance for major care.

          • Crowns, cast restorations, inlays, onlays, and veneers:

            • Covered only when the tooth cannot be restored by amalgam or composite resin filling
            • • Replacement is not covered unless the existing crown, cast restoration, inlay, onlay, or veneer is more than five years old and cannot be repaired.
            • MAXIMUM PLAN ALLOWANCE (MPA)
            • The MPA is the maximum amount the dental plan pays for covered dental services. The MPA applies to network and out-of-network dental services.
            • For covered network services, the MPA is that portion of a provider’s charges covered by the dental plan as determined by the provider’s contract with Delta Dental of Arkansas.
            • Network providers agree to accept an amount negotiated by Delta Dental for covered services as payment in full, subject to applicable deductible and coinsurance amounts.
            • Delta Individual
            • So, at best – the Individual Plan pays 50%. Group Plan pays 50%, so in this case, near as I can tell, you wouldn’t get anything extra as your Walmart Plan has Non Duplication of Benefits and not the “normal” Coordination of Benefits which would have allowed you to collect up to 100% of what the dentist charged you.

            • Please note, I’m not an attorney nor an authorized claims representative for Walmart nor Delta Dental.

#Denti Cal Beneficiary Handbook 2023  

denti cal handbook

Medicare and other Coverage 

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Medicare #DualCoverage
Publication - 02179  

How Medicare works with other coverage

 

#Subrogation
Medicare's Right to collect from other 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.

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.

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MLN Medicare secondary Payer

Medicare secondary payer

 

Medicare Secondary Payer Manual

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from December 2021 through December 2017 

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Medicare booklet on understanding mapd Medicare advantage plans

 

  • MAPD Plans look like a great deal, as the "premium" is paid by fee from the Federal Government, on average $2k/year.Kff *  MAPD Plans must cover all A & B services Medicare.Gov * generally they also cover Part D Rx.
  • That's why the premium is very low or ZERO!

Cal Medi Connect 

Historical 

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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
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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.

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Consumer Links

Some Cal Medi Medicare MMP Default Plans:

Technical Links

Other pages in Medicare Advantage Section

  • Additional Social Services – in addition to Medi-Cal
  • Medi-Cal Estate Recovery
  • Blue Cross Medi Medi – Co Ordination Plan
Long Term Care Information - Private, Medicare & Medi-Cal?

Cal Medi Connect
Guide Book

cal medi connect

Primer on Dual Eligible – Those on Medi-Cal & Medicare

primer dual eligible

CMS on people dually eligible for Medi Cal & Medicare 

BROKER ONLY

Guide to Dual Eligible Special Needs Plan 2021 

 

How to Opt Out of Cal Medi Connect

Cedars Sinai – Plan Section Tool & Info

Cal Medi Connect
Video’s

Animated Video Explanation  
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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

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

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

  2. I have Original Medicare A & B, start date 10-01-22 and ffs Fee for Service Medi-Cal .

    https://www.dhcs.ca.gov/provgovpart/Pages/Medicare-Advantage-Information-for-Dual-Eligible-Beneficiaries.aspx

    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.

    Reply

  3. Can child qualify for medi-cal with one parent, when the other parent in a different household has private/ employer insurance for the child

    Reply

  5. 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

    Reply

  6. 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.

    *********

    My son who is 10 is currently under a waiver by the local Regional Center to receive MediCal.

    I also have him under my employer insurance but i was thinking of removing him from my employer insurance to improve his care due to a lot of issues this year to get him medical equipment.

    Will this affect his eligibility for the waiver and lose his Medi-Cal?

    Reply

    • 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.

      ****

      Sorry, I don’t have time right now to research questions that I don’t get compensated for, with the war in Israel going on and some of my own family issues with SSDI.

      See above about Employer Plans paying first and if they don’t pay, then Medi Cal will.

      If your having problems, contact someone at Medi Cal and hopefully you’ll get the correct authoritative answer.

      Reply

  7. 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!

    Reply

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