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.
- 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.
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.
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.
- Denti – Medi Cal and other dental plans See page 19 of Dental Member Handbook
- 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
#My Medi-Cal
How to get the Health Care
You Need
24 pages
Smart Phones - try turning sideways to view pdf better
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.
- Get a lot more detail & analysis on Medi Cal HMO providers see our webpage on that
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?
- 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.
#Report changes as they happen - within 30 days! 10 CCR California Code of Regulations § 6496 10 days for Medi Cal 22 CCR § 50185
IRS Form 5152 - Report Changes
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
#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
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?
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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
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:
- 1. May not include individual or family policies, or individual or family subscriber contracts, except… § 1300.67.13. Coordination of Benefits (“COB”)This all is rather complex. Let me email Delta to double check.See our webpage on dual coverage….Non-duplication of Benefits
- 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
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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
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(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.
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(b) For purposes of this section, the following terms have the following meanings:
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(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.
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Please note, I’m not an attorney nor an authorized claims representative for any Insurance Carrier.
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Medicare #DualCoverage
Publication - 02179
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VIDEO how two plans coordinate and pay your claim.
- 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
- Medi-Cal (for People with Medicare) – 04-19-23 Hi Cap CA Health Care Advocates
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.
- Medicare Guide to Dual Coverage who pays first publication # 02179
- Medicare website, on dual coverage
- 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.
Medicare Secondary Payer Manual
For more information - Also see our desktop version
#Understanding Medicare Advantage Plans (PDF) #12026
- Set a Zoom Meeting
- We can now do SOC Scope of Appointment, before the Meeting via a 3 minute recorded meeting 2 days before. AHIP Training Module 4 Page 14 *
- #Intake Form - Please email us [email protected] for the form - That way we can better analyze your situation to give you the answers to your needs and questions.
- 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!
- Visit our general webpage on Medicare Advantage for much more detail and information.
Cal Medi Connect
Historical
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
- 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.
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
- Additional Social Services – in addition to Medi-Cal
- Medi-Cal Estate Recovery
- Blue Cross Medi Medi – Co Ordination Plan
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
How to Opt Out of Cal Medi Connect
Cedars Sinai – Plan Section Tool & Info
Cal Medi Connect
Video’s
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