Dual Coverage FAQ’s

See also our MAIN Dual Coverage  page and more recent FAQ’s  

FAQ’s –  “Dual Coverage?

  • 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.  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. 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?
    • 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 coverage.  See above contact information for Kaiser & Medi Cal. Check with them.
    • If I currently have Medicare Advantage, can I also obtain another private health care plan (as secondary payer)?
      • If you are talking about getting a Medi Gap plan, NO.  It’s llegal to sell you a Medi Gap plan, if you have Medicare Advantage. See page 78 of the Medicare & You handbook.
        Did you want to check out extra dental & vision coverage?
        Was there any specific type of claim you had in mind?
  • I plan on driving for Uber & Lyft in the near future.  They both offer stipends for Heath Insurance policy costs. They do not however, offer the stipend on Medicare.  I was recommended by someone to obtain a low cost supplemental Private policy to qualify for the stipend. I can understand Uber/Lyft disqualifying Medicare Part A (hospitalization) because that is of no cost to me; but I cannot understand why Parts B (outpatient/medical), C (via Kaiser HMO) or D (prescription drug) are disqualified (as well) when I have to pay $145/mo out-of-pocket for BCD  It doesn’t seem equitable for Uber/Lyft to discriminate against one type of out-of-pocket policy over another.  That is why I am researching for Private carrier insurance to supplement Medicare. I’m not referring to Medi-Gap.
    • Here’s what we have on Covered CA and Uber/Lyft paying 82% of the Bronze Premium.You might try taking a dental policy, life insurance or something, but that doesn’t seem to fall into the agreement that Uber/Lyft made with ???If you have Medicare Part A for free, it’s illegal for Covered CA to write you up. However, if you already have Covered CA, it doesn’t seem they have to cancel you, they just won’t give subsidies. Our webpage on that.I’m not sure what you mean by a supplement to Medicare, other than Medi Gap or MAPD. With MAPD how are you going to get a bill to send to a supplemental carrier.Please review our webpage referenced above on the Uber/Lyft agreement to pay 82% of Bronze and ask questions there. We haven’t read all the material. We haven’t had a single uber/lyft driver ask us to get them coverage. Prop 22 has been declared unenforceable, so I don’t even know if the stipend is still valid.
  • Medi-Cal to Private Insurance  1) I quit my job and I enrolled in CoveredCA but I was referred to and approved by Medi-Cal. I didn’t want Medi-Cal and I got Private Insurance at full price from Blue Shield since I was within the 60 day SEP period and cancelled Medi-Cal.  Now I only have Blue Shield.  Is that ok?   2) This is a hypothetical question.   If I had enrolled for Cobra instead would I still have been able to switch to Private Insurance within the 60 day SEP period.
    • 1. Sure, it’s OK, you are just not getting any subsidies. Here’s our webpage on Blue Shield HMO, PPO direct & Medi-Cal You can compare coverage and provider lists there.Use this link to appoint us as your Blue Shield broker, no extra charge. We don’t get paid just to have this website and give better answers with a citation than Medi Cal, Covered CA or even Blue Shield does.Are you sure you were really able to “cancel” Medi Cal? If not, no problem as private coverage is primary, see webpage above.Note also, an advantage that may come up is that in the past, Medi Cal took the premiums they paid out for people over 55 from their estate…2 We will answer the question about 60 day SEP on our Special Enrollment Page.
  • I have my primary medicare A and B. I also have medi-cal. Otherwise known as medi-medi.  Lots of doctors are now opting out of the medi-cal part. I offered to pay them the balance of what medicare doesn’t pay. They say they’re not allowed to bill me the balance, it’s against the law because they’re not a medi-cal provider member.   Am I allowed to buy a supplement to medicare so these doctors will see me?  I don’t want to lose my medi- cal however, as I get my IHHS benefits from them.  Will it be legal to buy a supplemental policy of choice eg: Blue Shield, to offer to the doctors who won’t see me otherwise.  I’ve called SS and medi-cal and asked if it was ok and they just say, “Uh, I think so”!  That answer is not good enough for me. Incidentally, my son will be paying for my supplemental premium.
    • Right, it’s a confusing situation that providers can’t bill you for anything not covered by Medi Cal. See our Q & A below on that
    • I see two ways to get extra coverage…
    • 1. Medi Gap – The issue would be finding a guaranteed issue time so that you don’t have to fill out health questions. If you are perfectly healthy we can apply anytime, just complete the application and pay the premium.
    • Here’s where Medi Cal even allows the premiums on Medi Gap to lower the Share of Cost for those people that it applies too.
    • Here’s our webpage on when you can get Medi Gap guaranteed issue. Namely, if you have a change in share of cost
    • 2. Medicare Advantage MAPD    We offer Medicare Advantage with Blue Cross, United Health (AARP) and Blue Shield. Please visit our webpages and verify that your doctors accept those plans.  Here’s our webpage on when one can enroll in MAPD Medicare Advantage    So, if you find a plan that covers your MD’s we can set you up. If you email us your MD list, we can check for you. [email protected]    Excerpt from Official Medicare Pamphlet on Understanding Enrollment periods page 10     Here’s our webpage on IHSS In Home Supportive Services   Page on how to get the Part B Dr. Visit premium paid by Medi Cal
  • My 22-year-old disabled son has private insurance as primary and Medi-cal as secondary insurance.  His Medi-cal insurance was not a HMO plan until March 2020 when we were told that we had to choose a Managed Care Plan for him.  According to some of your former replies, it seemed that my son shouldn’t be forced to choose a HMO Plan?   That said, he currently has Healthnet PPO and Santa Clara Family Health Plan.
    • My question is   whether you know is it beneficial for us to continue his Healthnet coverage starting 2022?   Because of his secondary being HMO, we need to get referrals prior to seeing any specialist anyways.
      • I really need to see the EOC Evidence of Coverage for both plans.  Do you like being able to use the PPO Provider List for Health Net rather than the HMO list for Santa Clara Health Plan?  Why do you have to use the secondary HMO? What are your co-pays with Health Net? What is your premium with health net?  How about appointing us as your broker on Health Net? Your own coverage?
  • I have compared the EOBs [Explanation of Benefits] from both Healthnet and Santa Clara Family Health Plan.  SCFHP in fact covers more but obviously, the providers get less money from them.   I have checked that Stanford does take SCFHP and zero copays for my son. I just have to make sure my son gets all the meds and medical equipment he needs with only SCFHP. I will be reaching out to his current providers to see if there will be a problem having just SCFHP. It’s more and more obvious to me that having only SCFHP may suffice.
    • For more information see our webpage on balance – surprise billing.
  • Definitions of EOB Explanation of Benefits Care Credit * Health Partners *
    • I don’t really think you can be concerned with the reimbursement levels… They are difficult to obtain and often considered proprietary. Here’s our webpage on the requirement for hospitals to post their charges online.
    • While if one looks real hard you might find Medicare reimbursement rates… Anything else is difficult and next to impossible. If you find it, please post here.
    • If Medi Cal doesn’t cover something, you might try the appeals process.
  • “HMO – Managed Care Providers”
  • Stanford Medical told me I would have to drop my Medi-Cal to get their full financial assistance (charity care)?   I was told that I could not come to Stanford for any health care if I was a Medi-Cal recipient……… because then Stanford would be committing FRAUD. I was told I would have to ‘quit’ my Medi-Cal or get the permission from Kaiser (who I have for my Medical-Cal) to see a ‘out of network’ surgeon…….  How do I opt out of Medi-Cal?  If I quit or gave up my Medi-cal , will I be able to reinstate it or reapply when I am ready…assuming I still qualify/?
    • Kaiser only allows one to have Medi-Cal through them if you were previously with Kaiser https://thrive.kaiserpermanente.org/medicaid/medi-cal-california/how-to-apply so if you drop out I doubt that you’ll be able to get back in with Kaiser and you would have to use another Medi-Cal HMO
    • Hypothetically, what if Stanford messes up the procedure, do you think Kaiser would want to have to fix that.
    • If you drop Medi Cal, what about other health services that you might need?
    • Will any of the other Medi-Cal HMO’s allow them  to do the surgery that you want because it’s my understanding that you could change Medi-Cal HMO anytime you want
    • I’m in Los Angeles, the Medi Cal rules are different for every county, even though it the same federal Medicaid law…. Here’s a list of the Medi Cal plans that Stanford accepts stanford health care.org/medi-cal
    • What reasons do you qualify for Medi Cal on?
  • My mom got diagnosed with stage 4 lung cancer(which has spread to brain) last week at Stanford Emergency center. She has Medi-cal managed health plan(Santa Clara Family Health plan managed by VHC). Stanford is in-network only for emergencies and things the community hospital can’t provide.  Medi-cal denied our request to be seen by Stanford doctor and has referred us to valley medical center.  When I asked stanford about seeing doctor there and paying out of pocket they said if I do that she will lose her Medi-cal insurance.  Even if I try to get second opinion she could lose her medi-cal….which is so strange to me. Can you vouch for that ? how would medi-cal know ?  Can I get second opinion out of state(john hopkins or some other medical center) and will she still be at risk of losing insurance ?  Also, I was trying to find a insurance plan that can include stanford cancer specialists and found one by Health Net (PPO). But read really bad reviews about them on consumer reports(shady tactics to avoid paying).  Do you recommend any insurance plans that are hassle free from patient perspective that I can pay out of pocket for her treatment ?
    • “If you have been enrolled in a Medi-Cal Managed Care Plan for more than 90 days you cannot get a medical exemption and you should not submit this form. ”
      • Since my mom has been enrolled in Medi-Cal qualifying for exemption is not an option.
        • I don’t have ready access to Santa Clara’s Family Health Plan Member Handbook or EOC Evidence of Coverage. LA Cares Member Handbook says you can get a 2nd Opinion from an IN NETWORK provider It doesn’t look like Independent Medical Review applies…
        • Under the Medicaid (Medi-Cal) program, a provider agrees to accept payment under the Medicaid program as payment in full for services rendered. A provider may not make a private pay agreement with a beneficiary to accept a Medicaid fee for a particular covered service and then provide a different upgraded service (usually a service that is beyond the scope of the Medicaid program) and agree to charge the beneficiary only the difference in fee between two services, in addition to billing Medicaid for the covered service.
        • It is an unacceptable practice to knowingly demand or collect any reimbursement in addition to claims made under the Medicaid program, except where permitted by law. New York – College of ER physicians
  • What if you have your Mom live with you and you take her as a dependent?  Then maybe she will qualify for Covered CA subsidies?
    • What would be your combined income? Here’s our webpage on rules for a household taking a dependent.
    • Here’s where to get quotes, based on household income… for Covered CA.
    • Here’s where to get more details on each Insurance Company in Covered CA.
    • Sometimes it’s difficult to get out of Medi-Cal
  • I could spend on private insurance to at least see the doctor of my choice if not be treated by him.  I know little about how PPO plans work…could I literally buy an $800 a month plan just long enough to consult with Dr. xx?  Continue it just long enough just to be treated? Or would there be contracts and delays?  I’m also concerned Cedars might refuse to give me an appointment without the medi-cal being fully cancelled.  I’m willing to cancel it but again there could be delays from state documenting cancellation.
    • Here’s our quote engine to get Blue Shield PPO You can get quotes there or here.
    • Private coverage would pay first, so I don’t think you would then be considered a Medi Cal patient and have the prohibition of the doctor or hospital being accused of fraud, see above.
    • I’m NOT an attorney or authorized representative for Medi Cal! Thus, I’m NOT giving you any advice or recommendation!
    • See our webpage on surprise & balance billing.
    • Try the Medi Cal Ombudsman? and Complex Assistance See our contact page
    • Here’s the closest I’ve found to a citation in the law about a medi cal provider not being able to bill you for anything that Medi Cal doesn’t cover. Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997.
  • I have blood in my stool. Medi-Cal won’t let me have a colonoscopy for 3 months.  What can I do to get an appointment sooner?
    • What Medi-Cal HMO carrier are you with? Check out their EOC evidence of coverage for appeals procedures. See the list of providers that we have above. We might already have links.  Try using the contact information we have for Medi-Cal and see how they can help you. Medi-Cal has PAID staff to help you. We don’t get paid to help you.  Check out our appeals and grievances website.  Try filing with the Department of Insurance – Managed Health Care a request for Independent Medical Review.  Medical Necessity?  Review the clinical guidelines, for various types of colonoscopy.   Research meaning of blood in stool  mayo clinic.org//fecal-occult-blood-test/   Positive result. A fecal occult blood test is considered positive if blood is detected in your stool samples. You may need additional testing — such as a colonoscopy — to locate the source of the bleeding.   web md.com/fecal-occult-blood-test#1  web md.com/colorectal-cancer-overview-facts   How urgent is a colonoscopy?  I’m not a doctor, attorney or paid staff at Medi Cal. Check with them…
      • Reply from Medi-Cal  The individual would need to go through the doctors and health care plan in order to speed up the process.
  • I am in a dilemma,  1 I didn’t know I was approved for Medi – CAL (California) until I was taken to the emergency room (there were several bills, one for the facility, one for services rendered, and one for the doctor in the ER) visit unconscious.  2 I didn’t know I had any bills because I have TRICARE SELECT, US Military. I was under the impression Tricare was taking care of the bills.  3 I recently received calls that were being blocked by ROBOCALLER. Once I unblocked it I realized that the hospital billing was actually not a bad idea to figure out. Around $15k and I am still dealing with it.  4 My social security # and my address were incorrectly put in by the hospital. (and probably by good reason due to my head injury).   5 Where do I start, I am updating with TRICARE SELECT. as we speak.  6 But to be honest, I don’t even think I should have been approved for MEDI-CAL. I have tried to reach out to the local office where I had applied online for food benefits, still waiting on that response after 14 emails, no calls are answered, and I have no idea what to do there.  7 If so, and I leave the past approval of the Medi Cal in place, who is responsible for this bill? First payer and who is the second payer?  8 I realize it is out of the timeframe to file with Medi-CAL but the hospital didn’t have my information on file correctly, I never received a bill either nor was it ever to mind because I had a head injury. It was after 3 different companies, all being “bad collection” systems one lady finally said my social out loud. It was off by one digit. Updating that with the hospital now to.   9 It came from the White House that insurance companies have to consider the Pandemic, does that pertain to Medi-CAL?
    • 7. Tricare would pay first. See page above   6. If you qualify for Cal Fresh – Food Stamps, I would imagine that you would qualify for Medi Cal.   What is your estimated MAGI Income for 2021?   If your income or assets are too high, you may qualify for Share of Cost Medi Cal?  Medi Cal can backdate coverage for 3 months!   Hospitals I guess can apply for patients under the Hospital Presumptive Eligibility HPD program.  See our Medi Cal Contact page… maybe you can try the Medi Cal ombudsman? How about setting up an online account with Medi Cal?  9. I don’t see how the pandemic applies to your situation.   5. I think that is your best bet… Have Tri Care pay their share. Did you show your Tricare ID card to the hospital?   1. If you were approved for Medi Cal, why didn’t they pay?  3. Why are you being harassed if you have Medi Cal?
  • “Medicare – Dual Coverage – Subrogation”
  • I’m turning 65 and I have an individual plan that doesn’t have a co-ordination of benefits clause along with a Covered CA plan. I’ve been able to collect twice as the individual plan doesn’t have a co-ordination of benefits clause.   I’m turning 65, it appears that my individual plan, won’t duplicate benefits with Medicare.  Does that mean I can’t collect twice? Can I collect up to 100%?
    • Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).
    • Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments. CMS.gov
    • noun: duplicate; plural noun: duplicates  /ˈd(y)o͞opləkət/Submit  1.  one of two or more identical things.  “books may be disposed of if they are duplicates” Google  Click here to enroll in Parts A & B   Use menu above to view options on Medi Gap and Medicare Advantage Plans and the pros & Cons
  • Dual Coverage Questions from a website visitor   Answered in Interlineation
    • My wife (I have full authorization filed for disclosure) is 69 and coverage by traditional Medicare (A and B) and also has group health insurance under a group of less than 20 employees.    ***Thus Medicare pays first.    She had an accident and fractured her teeth requiring implant and new porcelain/ceramic pontics.   ***Thus Medicare would pay for an accident, but not routine dental.   Claims were submitted to BCBS of Florida who says we should have first submitted the claim to Medicare.   ***That’s correct, as Medicare pays first, then your group plan picks up the rest.   I have already paid directly for the services.    We reside in Florida and there were two D.M.D.’s (Doctor of Dental Medicine – same as DDS) involved in providing the services.   What do you recommend?  ***I suggest that you just send the bill to Medicare.  Then resend to your group plan, once Medicare has paid.  (Also, when we look at my wife’s profile online   ***Do you mean her Medicare profile? http://www.MyMedicare.Gov?   it doesn’t list the supplemental carrier at all. How to we correct that?   ***Send me your password privately and I’ll figure it out.  Medicare also has a customer service and live chat on the website.  They should be able to help you.
  • “Dual Coverage – NOT Medi Cal – Who pays 1st? Collect Twice? Individual Plans”
  • Primary vs Secondary in emergency   We cover adult employed daughter under age 26- she received coverage from her new employer November 1.   On November 14 she was in a bad accident and required emergency care. She gave her Blue Shield information. Her injury and subsequent care have been extensive including emergency spinal surgery in December.   We just received notice from Blue Shield that effective November 1 Kaiser was primary and should be paying the costs.   What are our rights in this case?   The notices from Blue Shield are addressed to us as she is the dependent.
    • We need to see the letter you got from Blue Shield. We are not allowed to accept hearsay.    M. “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:   (1) The plan either has no order of benefit determination rules, or its rules differ from those permitted by this regulation; or  (2) All plans that cover the person use the order of benefit determination rules required by this regulation, and under those rules the plan determines its benefits first. NAIC Model Rules  So, if you don’t go to Kaiser they won’t pay. Thus, Blue Shield will pay at a non kaiser facility.   Do NOT take this answer to the bank. We need the letter and your EOC’s Evidence of Coverage. If you don’t have ready access to your EOC, give us the exact name of your plan, we probably have access to them.  FYI, Medi Cal doesn’t allow one to get an HMO if other coverage is available!   Kaiser Group Information   Blue Shield Individual & Family Information   Our webpage on reading Insurance Policies and the Law – Read 3 times, then when you think you understand it, read again.
      • The letter that my husband received from Blue Shield, after looking more carefully this morning, are actually copies for his information that were sent to the health care facilities and the hospital where she was taken. The letters tell the facilities that they should be billing Kaiser.
        • If you’d like a copy to see what it says, please let me know how to get it to you, or if you’d just like the transcript here.
        • Also, the coverage we have had for a few decades is Blue Shield of CA, HMO.  My email is encrypted coming and going by Paubox.com or you can upload to https://www.paubox.com/steveshorr/upload
        • I need an EXACT name of the plan that you have with Blue Shield and your daughter has with Kaiser. If it’s an individual plan, it might not be allowed to have a co-ordination of benefits clause, see webpage above for citation.
        • Since your daughter was in the hospital for an emergency, Kaiser would probably have to pay for it, even if not in their facility.
        • Please advise exact name of plan. The EOC is 10 times easier to review, than trying to piece together all of the various laws and statutes.
        • I just sent a copy of the letter to the link you provided. And the name of the insurance we carry is Blue Shield HMO, Pomona Valley Medical Group Inc. DBA, Pro Med Health Network A+… Does that help?
        • No, I need the exact name of the plan or your EOC. Please visit the links above for our Group and Individual Blue Cross pages. It’s my understanding from above that there is no co-ordination of benefits on an individual plan.
        • Rather than spend hours researching the law, pro bono, the answer is in your EOC.  How about sending a copy of your ID card?  Here’s the relevant portion of the letter from Blue Shield to the hospital.
        • This is just a routine letter from Blue Shield letting the hospital know that under the rules for Coordination of benefits, Kaiser is supposed to pay first. If there is any portion of the bill that Kaiser doesn’t pay, then Blue Shield will pay up to their limits. It looks all routine to me.
        • I believe your concern is that you think that Blue Shield is saying you HAVE TO GO TO KAISER and not Blue Shield. There is nothing in the letter that says that.
        • I’m sure if you send me the EOC’s there is nothing there that says that.
        • Go to whatever MD you want, as long as they are on Blue Shields or Kaiser’s list.
        • It seems to be quite tricky to actually FIND our EOC docs! My husband has sent and email to his HR department because the Blue Shield member page tells us “we may not be able to access” all the documents, and it seems the EOC is one of them? Is there a way around this if his HR department doesn’t come through?
        • Go to our Blue Shield Employer Plan administrative Webpage
        • Then click on the forms image  Watch Loom Video for more details  No one is telling you that your daughter must go to Kaiser, right? So, why worry? What difference does it make which plan pays first for the emergency care? The 2nd plan will pay after the first one does.
        • Normally, we do NOT deal with 3rd parties for competent adults. If you are going to ask more questions, we need you to “certify” that your daughter is too severely injured to handle this on her own.  Here’s where we enrolled a woman in Covered CA who had been in a major accident with her parents. When she got better we were accused of Fraud, etc. as she qualified for Medi Cal. Comment 1 ** 2
        • Forgot to add… we literally have no record of the Kaiser plan. It was provide through a small organization in northern California called Animal Place. I believe it’s small group insurance in that case. Nothing fancy…
        • Try asking your daughters employer. Kaiser has dozens of different offerings. I’ll grant that their group plans may all have the same co-ordination of benefits… but why gues? Just let me know the exact plan, then we can review the EOC.
        • If you want to read the entire Insurance Code Regulation Section See link above in More Explanations section  See UHC EOC explanation at the very top of this webpage
        • Thanks so much Steve – your information thus far has been amazing for us! The video was awesome and if we need further help, I’ll surely reach out to you!  Thanks again!
  • What are the rules with dual coverage in regards to  COBRA for the husband & a group plan for wife?  The Primary (person A)  ***[How do I know, who is primary? I need to see the documents]  If you are covered as an employee, member or subscriber under more than one plan, but are covered under state or federal continuation (COBRA) under one of the plans, then:  The plan covering you as an employee, member or subscriber is primary over the plan covering you under state or federal continuation (COBRA). illinois.gov   has health insurance through their job, loses job, continues COBRA coverage for the family, meets the maximum deductible of $4000, [individual and/or family deductible] they have 0% out of pocket expenses now except for the monthly premium of $1,442.  Mid-year the spouse (person B) now gets a job with health insurance coverage through their employer.  The premium is much less $338, deductible of $3,000 with 80% coverage for in-network.  If they cancel the COBRA, then they pay a new deductible +20% of medical charges incurred. If they overlap and have dual-coverage, then they are really paying extra money for the second medical plan $338/month with little benefit   ***I don’t quite follow, sounds like more benefit  -since they’ve met their deductible and pay 0% out of pocket.   What if the family has dual coverage for 1 month, then after the second month they cancel COBRA?   Do they still have to meet the new deductible of $3,000?   ***I’d have to see the new policy. I doubt there is any take over provision.  Thus, yes.   Does the insurance company only look at charges that have occurred within that month of dual coverage in order to determine if deductible B $3,000 has been met?   ***Deciding what medical bills go to the deductible has nothing to do with having other coverage.   How do they determine when it’s beneficial to have dual coverage?   ***The Insurance Company doesn’t decide if it’s better for you. That’s your decision. Why pay $1,442 to have dual coverage? In two months, you have the $3k deductible taken care of.  Also, the $338 contribution as the employer is paying the rest of the premium, is probably tax deductible, if the employer has set up a Section 125 POP Plan.   This is a cut & paste of a question we had on another page. We are putting it here, to better consolidate our website and put everything in a more logical order.
  • I have pretty good Cobra Insurance (Health Net PPO, eligibility expires 12/17), however, I am concerned with the current political climate, Obama Care may go away and when I am no longer eligible for Cobra, it might be difficult to get insurance due to pre-existing condition or other medical related risk factors becoming a factor as they were in the past. To protect against that, I would like to get a Blue Cross PPO now
    • See our quote engine above for quotes     In the past we had HIPAA for those who lost COBRA. There was also MR. MIP – High Risk Pools.   and just continue it until my Cobra expires.   ***Losing COBRA gives you a Special Enrollment Period   So therefore, I would have two health plans. My current Cobra group plan and an individual/family Blue Cross PPO plan.
      • The questions I have are:   Can I have two health plans (I’m not trying to commit fraud, I understand I cannot get paid more than the bill).
        • Dual Coverage & Co-ordination Rules   Let’s see if the question is asked on the paper application – I’m looking at doing this direct, no Covered CA no subsidies. For subsidies, the answer would definately be NO.  Question G 2 asks about other coverage and if you plan to cancel it. So yes, you would have to disclose other coverage. I doubt they would write you. If it’s that important to you I could email them and ask. I could also check the ACA rules and see if the ACA law says you can buy coverage, even if you have other coverage.   Do I need to tell Blue Cross?  Yes, since they ask.  Can I pick and choose who I want to use, if Blue Cross   Please get a quote proposals, benefits, subsidy calculation. I don’t think Blue Cross has a PPO in your area. Try Blue Shield.  has a doctor I like or pays more benefits for a particular procedure, can I only use them.  These questions are quite complex and I think I’m going to have to charge a research fee for them. Under ACA, I practically have to work for free.   See our page on Dual Coverage, see also the rules in the current evidence of coverage, if we can even get you an extra policy, that we do NOT recommend that you purchase!  The same for Health Net PPO, use them if they are more beneficial for the procedure I have. – Please answer for Blue Cross, I have already got Health Net’s comment.  Verbal comments are worthless!!!   See the rules on dual coverage, basically the 2nd company pays up to 100% of what the first one didn’t. It may well be that there is NO co-ordination of benefits clause on two INDIVIDUAL policies. Thus, you could collect more than 100%, which is why I don’t think you will get a policy issued, if you plan to keep the first one.   Note too, that I won’t give an answer, unless I can show it too you in writing or the law. I don’t want to have to pay the claim out of my pocket.   My intent it to cancel my Health Net policy down the road   I think you should keep it, till you really want to move and it expires. There is also Cal COBRA, which gives you another 18 months of coverage.   but I have had it for 15 years and am leery just to let it go.   Also, I go to doctors who do not take insurance. Can I go to doctors who do not take insurance and not let Blue Cross know I am having a procedure done?  If you have a PPO, you could still turn in the claim. When a MD says they don’t take insurance, that just means they don’t agree to the negotiated rate, they still will cash the check.   Usually the bills are below the deductible or I don’t want to wait for an approval – like an MRI)  The question is beyond my pay grade.
  • I worked at a company that paid fully for our health benefits. I quit, but they didn’t take me off their coverage for 6 months. They prior insurance company still paid for my Rx Prescriptions.  One of the medications that was claimed with my old insurance needed a prior authorization in order to fulfill. Since my new insurance won’t cover it who is liable?  Will the ACA clause regarding recession of coverage protect me from having to pay?
    • I’m a little confused about what you are asking.  Do you mean which insurance company pays for the 6 months you had two plans?  Do you mean who pays when you only have the new coverage?  Will your new insurance pay for the Rx if you get an authorization?  What do you mean by “liable?”  What ACA law on rescission are you talking about?
      • The former plan was inadvertently continued for 6 months following the date I quit. Doesn’t that mean that coverage terminated is effective as of date they realized the error?   I was considered active with both insurers so in theory either of them would be able to pay my claims during those 6 months. It just so happened the new pharmacy I used took the insurance company from my past employer because it’s what showed up as active in their internal system.
        • I can see them doing a retroactive termination. You were no longer an employee and not entitled to benefits. Especially, not paying any premium.   Check this page for more information on what the eligibility requirements are for an employee employee-definition/
      • Hard to say, if my new Insurance Company will approve the Rx. Assuming they don’t deny the authorization, the date that they authorized is after the date I filled the prescriptions.
        • What Insurance Company are you now with? Which Plan? What is the name of the Rx? Why do you need it?
        • See this plan on how to request a formulary exception. prescription-formulary-approved-list/
      • If the old insurance takes me to collections am I liable to pay them ? Or is it the pharmacy if they never collected my insurance information liable? Or is my old insurance based on my old employers mistake/HR error?
        • These are very good questions. How much $$$ is involved? What I’m getting at is that apparently you were never offer COBRA.
        • It’s my understanding your employer, HR and the Insurance Company can get in BIG trouble for not doing that.   https://www.shrm.org/resourcesandtools/tools-and-samples/hr-qa/pages/howcanemployerscorrectcommoncobraadministrationerrors.aspx    https://tax.thomsonreuters.com/blog/no-penalties-for-cobra-violation-absent-proof-of-employees-harm-or-employers-bad-faith/   Grandfathered Plans count as MEC – Minimum Essential Coverage http://bit.ly/2CWFpo0   BUT, the IRS Flow Chart on page 5 of Publication 974 http://bit.ly/2DwU4Yo says individual plans don’t count. So, I guess you are good. Please double check with competent tax and/or legal counsel.    IRS Instructions to Form 8962, “Coverage in the individual market outside the Marketplace. While coverage purchased in the individual market outside the Marketplace is minimum essential coverage, eligibility for this type of coverage does not prevent you from being eligible for the PTC for Marketplace coverage. Coverage purchased in the individual market outside the Marketplace does not qualify for the PTC.”   While it looks like rules allow people to have both on on-exchange and off-exchange health plans, and receive the APTC, I don’t think people should expect the health plans to completely cover any health care claim twice.
  • Please expand on this paragraph:  “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.”   We have (Blue Shield HMO) (paid by employer); and (Medi-Cal via IEHP; no-shared-cost)….   It would seem that most medi-cal providers do not bill correctly for this dual-coverage; and we end up paying for these copays; when we never paid them before… More coverage = less benefits…   I went to the hospital for infection; the bill for nearly $3000; with approx 40% paid by insurance; so we received bill for approx 60%…   The hospital said we must pay an additional $50 copay; before they can resubmit the bill to insurance…  1) How should providers be billing in cases of medi-cal with additional insurance; specifically with copays, deductibles, etc…   2) Should/can I seek reimbursement for these fees paid?
    • 2nd if you have other coverage like your employer plan, you can’t get a Medi Cal HMO. See response from Medi Cal Ombudsman  Did you report your employer coverage to Medi Cal?  Yes, I would try to get reimbursed… The problem is, do you really want to cancel IEHP and use fee for service?  On the other hand, you have no choice but to report your employer health coverage and go on fee for service.
  • [Other Health Coverage (OHC) and Medi-Cal]
  • My family has been on (Medi-Cal via IEHP) since at least 2012… My wife got employed at a local college in 2019; after the Covid-19 pandemic… We notified medi-cal; as required by law; of both added income and 2nd insurance (Blue Shield HMO, paid by employer)   Medi-cal enrolled us in “transitional coverage”, good for 3-6months…. Due to laws, my state coverage could not be terminated during the Covid pandemic, so lucky to maintain my coverage.   So my questions; issues; was in regard to copay/deductible fees for (OHC)(Blue Shield HMO) services; should be paid by (Medi-Cal via IEHP)… The service providers have been making me pay these fees out-of-pocket… I tried to argue that fees not paid by (OHC); should be paid by (Medi-Cal via IEHP)… How should I proceed?!?
    • Your question is beyond our pay grade.   Here’s our webpage on appeals & grievances  Here’s our webpage on how to read a policy  Heck, I have to look up what transitional coverage is. It’s for if you earn too much money to qualify for Medi Cal, they let you stay there for up to a year.  I don’t see what that has to do with going on fee for service.   Under FFS, Fee for Service the 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.  Check your IEHP Medi Cal Handbook for appeals procedures & dual coverage. Page 67 See page 65 about Medi Cal as payer of last resort.  IEHP is an HMO and thus doesn’t pay, if you don’t use THEIR doctors.  Sounds like Medi Cal made a boo boo not putting you into fee for service when you told them you have other coverage.  On the other hand, they let you stay in Medi Cal, with too high an income.
    • How about checking out Covered CA with subsidies. They are now especially high under ARPA. Nah, nevermind, you won’t get subsidies as you have employer coverage.   Good point! Send a copy of the manual to the hospital!
  • My daughter and I have medi cal but my husband doesn’t. He has Medicare because he is disabled.  My daughter and I have medi cal dental and medi cal insurance.  My job offers dental and vision.  Can I put my whole family on it?  Or does my daughter and I stay with medi cal dental.  Can I just enroll my husband through my work?
    • I presume that you and your family meets the “standard” definition of dependents for employer groups right?    So, why not cover everyone under your employer plan? It would save the people of CA money on their taxes!   What is the employee contribution to add yourself and your dependents?   It’s clear from the webpage above and citations that if you have other coverage it must be reported to Medi Cal.   I’m having trouble finding a citation that you must report “available” coverage.   There are situations where Medi Cal will pay for Employer Coverage. Does your employer offer health coverage?   See this article about Medi Cal and Employer Coverage.   I really need to see the information from your employer as to what their plan will allow for you to enroll yourself and your family…
    • Reply from Ombudsman
      • Good afternoon Steve,Thank you for contacting the Office of the Ombudsman.If a Medi-Cal beneficiary is not receiving other health coverage then Medi-Cal will remain their primary insurance and although other coverage is offered by their employer, if they opt out of the plan, then that information does not need to be reported. It’s only reported when it is active.Have a wonderful weekend.Best Regards,Office of the Ombudsman, 360
        Managed Care Operations Division
        ( (888) 452-8609 | * [email protected]
  • My 19 year old son was in a skateboarding accident in February and is in a coma with a traumatic brain injury. We currently care for him at home 24/7 but have been told that there are some services that would be available to us through Medi-Cal (IHSS, etc) if he gets on Medi-Cal.   We are currently on a Kaiser HMO through Covered CA but will be transitioning to a Blue Shield PPO (individual plan, not through Covered CA) in January so that he has access to more and better doctors that specialize in his condition. I have been told that we can put my son on Medi-Cal because of his disability (which gives us access to other social service benefits) but I am leery about getting him on Medi-Cal for fear of managing the PPO and Medi-Cal with respect to doctor access and such.  If he is on Medi-Cal (not MAGI Medi-Cal… but because of his disability) and on a PPO, will it impact our access to doctors, hospitals, treatments, etc? Will the PPO in any way be allowed to defer to Medi-Cal for doctor selections? Or would it be just like we had a PPO plan with no concern for Medi-Cal?
    • How about appointing us as your broker on the direct and Covered CA business. We do not get compensated at all for Medi Cal! We don’t even get expenses for this website.   covered-ca-agent-appointment-instructions/
    • Here’s our quote engine so that you can compare rates, whose on coverage, who isn’t. Subsidies, etc.?  quotit.net
      • Not all of you have to be on the same plan, either direct or with Covered CA.
    • Here’s information for IHSS In Home Supportive Services
    • So, basically, you would go to your Blue Shield direct PPO first. Then if the doctor is also a Medi Cal doctor, Medi Cal fee for service would get billed.   If your Blue Shield PPO MD isn’t also a Medi Cal MD, then Medi Cal won’t pay and you would pay any deductibles or Co Insurance, etc. Here’s our webpage for Blue Shield PPO   Here’s how to qualify for Medi Cal under the Aged & Disabled Program  
    • Here’s SSI  SSDI
    • Here’s the Blue Shield Provider Finder https://www.blueshieldca.com/fad/home
    • I know there used to be a Medi Cal, non hmo provider finder, but I can’t find it. Ask your county social worker.
  • Applying for CMSP   The County Medical Services Program (CMSP) provides health coverage for uninsured low-income, indigent adults that are not otherwise eligible for other publicly funded health care programs.   Resource Page for Medi Cal Doctors & Providers  HN confirms that if you have other coverage, you can’t get a Managed Health Plan HMO.
    • How about appointing us as your Covered CA agent, so that we can get compensated for helping you?  Exactly what plan do you have with Health Net?  What is your MAGI Income for 2020 & 2021?
    •  recently became pregnant and found out that my insurance plan doesn’t cover some things associated with prenatal care; such as ultrasounds and some testing.  I also found out that they only cover 60% of labor and delivery.   My husband was the one who chose the insurance and he didn’t know how the deductible worked at the time.  Now I am worried about the costs that are going to rack up for prenatal care, as well as labor and delivery.   Is it possible to apply for Medi-cal as a secondary insurance to help pay for ultrasounds, testing, and deductibles associated with pregnancy related healthcare??  This is our first year of not being on free state healthcare and I am really confused by how this would work.  Any direction would be greatly appreciated.
    • Under the Affordable Care Act, women’s preventive health care – such as mammograms, screenings for cervical cancer, prenatal care, and other services – generally must be covered with no cost sharing.   However, the law recognizes and HHS understands the need to take into account the unique health needs of women throughout their lifespan.
  • I have anthem blue cross ppo through college as student.  Also, I have full scope medi-cal which is managed by alameda alliance which enrolled me in kaiser.  I went to a doctor in network with blue cross, that doctor also is in medi-cal network.  Will medi-cal or alameda alliance or kaiser pay for my out of pocket cost?  Deductible was high so I’m trying to see how that coordination will work because it’s two competitors?  I think I saw somewhere that if local plan won’t pay that claims can be submitted under statewide medi-cal?
    • Normally, one can have Medi Cal pay as long as you use a Medi Cal provider.   However, Kaiser is an HMO click on the link and you’ll jump to the part of the page that explains it, and there you have to use their HMO Providers.  IMHO the best place to look for answers is in the EOC Evidence of Coverage.  I followed my own links above for the Medi Cal HMO Providers so here’s Kaisers Evidence of Coverage for Medi Cal.   See page 22 of the EOC about the requirement to use In Network doctors and providers. It appears to me you can only do that in an emergency.  I’m not authorized to confirm or deny coverage. Nor do I even get compensated to help people
  • We recently relocated to California.  My teenage son is autistic and he qualified for Medi Cal through our district regional center and not based on financial need.  I had also enrolled him with Cigna through my work with $1500 deductible. I was told all doctors visit needs to go through my primary health insurance first. But I have to pay the first $1500 out of pocket.  Is there any way I could keep my private health insurance while benefit from Medi Cal?  Any advice?
    • Please see the responses below to very similar questions  Must use Medi Cal MD’s  Must use MD’s on the Medi Cal HMO you get assigned to Also, we don’t care what anyone told you.  Please advise exact name of your CIGNA plan. There are probably co-pays for MD visits, rather than a $1,500 deductible, before anything is paid.  Is your child on SSI? That gets automatic Medi Cal.  See on above on Autism
  • Should medi cal pay Rx copays  since it what was not covered by primary insurance?
    • This section explains all of your covered services as a member of L.A. Care. Your covered services are free as long as they are medically necessary. Care is medically necessary if it is reasonable and necessary to protect life, keeps you from becoming seriously ill or disabled, or reduces pain from a diagnosed disease, illness or injury.
      • Prescription Drugs Covered drugs
        Your provider can prescribe you drugs that are on the L.A. Care preferred drug list (PDL). This is sometimes called a formulary. Drugs on the formulary are safe and effective. 
        If you are filling or refilling a prescription, you must get your prescribed drugs from a pharmacy that works with L.A. Care. You can find a list of pharmacies that work with L.A. Care in the L.A. Care Provider Directory at lacare.org. You can also find a pharmacy near you by calling 1-888-839-9909 (TTY: 711).
        Once you choose a pharmacy, take your prescription to the pharmacy. Give the pharmacy your prescription with your L.A. Care ID card. Make sure the pharmacy knows about all medications you are taking and any allergies you have. If you have any questions about your prescription, make sure you ask the pharmacist.
  •  I have SSI and Medi-Cal and work pt. 65 years old soon six months. I have a BON with Sutter Health PLUS but the county sent me booklets trying to force me On managed health care plans Sutter took for established patients so they must say that but are no longer taking these plans. I have to file an exemption to keep straight Medi-Cal my secondary and they denied it because they once took these plans! Nurse failed to write a justification letter for me. Sutter health PLUS is only for Sutter! I will lose my treatment plan and will become ill without it!
  • I thought it you had a primary insurance dual coverage shared cost I wouldn’t need to enroll in another plan. It says that like Medicare pays first! If I don’t have treatment I will get serious sick! The San Joaquin plan here doesn’t cover the medications I am on! Pharmacy said they don’t! It won’t work! No one seems to know what they are doing with the exemption forms! If I have dual coverage why and I being forced to take a policy that will hurt me? Ombudsmen referred me back to county! Long ago when I was on blue cross I found out a county worker forgot to put in my primary insurance.
  • If I am On SSI why am I being forced?   I have Medi-Cal from SSI disabled but work part time I also have Sutter health plus a HMO. Dual coverage. This is a shared medical cost. Recently they sent me managed health care plans and I won’t be able to use Sutter not taking new manager health care patients and my hmo at Sutter is only Sutter doctors. Can they force me for managed health care plans and lose my treatment? Sutter has to acknowledge they do have manage care patients. I read an article on here if I have share of cost I don’t have to enroll in a plan  I’ve also asked for help from https://www.ca-mentor.com/
    • Please review the material on our Cal Medi Connect Page. If you have further questions, that page would probably be a better place to ask.
  • When a person has MEDI-CAL and accident medical group insurance, in the event of an eligible accident under the group, who pays first
    • See above. Private coverage must be billed first.
    • https://www.ca-mentor.com/
    • Please review the material on our Cal Medi Connect Page. If you have further questions, that page would probably be a better place to ask.
  • I have a foster adopted child age 3. She is on med-cal but want to add her to our Sutter Health Plan to continue speech services. Is this possible will one of the plans be taken off?
    • You could add her to Sutter at Open Enrollment or if you have a special enrollment reason.
    • What do you mean, one of the plans taken off?  Do you mean, Medi Cal would be cancelled?
    • Not necessarily, see above for rules on how the two plans “fight” for who has to pay your claims.  I would think that Medi Cal would be mandated to provide Speech therapy if medically necessary, as it must be an essential benefit.  Maybe you need to file a grievance?
  • My 26 year old daughter is on SSI and has MediCal. She has been disabled since birth. We had her on our insurance through my husband’s company since with ACA she could stay on our policy. The PPO was her primary and MediCal was backup. She has complex health problems and once she turned 18 MediCal covered whatever the PPO didn’t. She has been working very part time (10 hours per week) for the last two years and when she turned 26 her health insurance started to be paid for by her employer also a PPO. Can she still have MediCal as backup?
    • She still qualifies for SSI right?  So she can still keep Medi-Cal  Disabled child was provided full scope medi-cal through the Institutionally deeming medicaid waiver. http://www.acts-at.com/resources/FUNDING/Institutional-Deeming.pdf
  • Child is also on parent private employer sponsored insurance too.  How should the billing/claims process happen when child only sees Medi-cal CenCal providers? Who is the Primary? and who is the secondary?
  • Can the parent take the disabled child off the private out of state self funded employer plan
  • Please review the above rules. Private coverage must pay first. I don’t know why people even ask the question of who is primary… Just turn in the claim and let Medi Cal and the Private Insurance figure it out, right? See also our main page on dual coverage.
    • While one might be able to take the child off the private plan, would you want to? Would you be able to put the child back on if you lose Medi Cal? Would you always want to be limited to Medi Cal providers? What about when the child turns 26? See our pages on how to keep coverage for disabled children when they turn 26?  
  • I have Blue cross PPO and medi-cal anthem blue Cross as a secondary.  I am wondering what my medi-cal covers after my PPO.  Is aflac Choice (hospital) option 1, a decent idea for me or worthless because medi-cal will cover most costs after my PPO?  Or would Aflac benefit me in  covering/refunding some expenses?  That possibly medi-cal won’t cover all of?
    • Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC (Other Health Insurance) payment amount, if any. Of course, you must use a Medi Cal provider. They are now all HMO’s!
    • I’m not familiar with the Aflac program, here’s their website .aflac.comThus, I can’t comment on their plan without possibly violating the CA Insurance Code ins-sect-790-03.html
    • IMHO how about getting coverage for serious things, like your retirement or life insurance to protect your income for your loved ones?
  • 1 I have Medi-Cal now. 2 My work is going to add a (very high deductible) insurance plan for us part-timers. 3 Just wondering if it would be better to NOT take the new (crappy insurance) and just have Medi-Cal. 4 I know that if you get private insurance they are considered the primary insurance. 5 I hear horror stories of how when people have a private insurance, that Medi-Cal won’t pay for stuff because they expect the other insurance to pay for it. 6 Plus, i also hear that I would also have to find a doctor who takes BOTH the new insurance and Medi-Cal which really limits the choices of doctors. 7 Are these things true? What are the pros and cons?  If it would be better to have a primary insurance PLUS Medi-Cal, then maybe I should get my own and pair that up with Medi-Cal.???
    • 2. What premium will you have to pay?  Is is more than 9.66% of your MAGI Income – Line 37 of your 2018 Tax Return?  Does the Employer Plan meet “Minimum Value?” – Bronze Level?
    • 3. You might not be able to qualify for Medi-Cal if your work is offering Bronze Level at an affordable premium. What is your expected MAGI Income for 2018?
    • 4. Double check that in your Medi-Cal policy and above in the Medi Cal and other coverage section of Medi-Cal what it means to you.
    • 5. Exactly. Why should the tax paying public pay for your health care if you have an employer plan that will?
    • 6. I don’t get paid to help people with Medi Cal. This is an interesting question. Read the other Q & A on this page. Check your policies. Check with your doctors. Use our Contact Page and Call Medi Cal. Check with your Employers Agent. Check with your Medi Cal HMO Provider.
    • 7. I don’t get paid to go into this…
    • Here’s where you can get quotes for unsubsidized plans, as if you qualify for Medi Cal, you won’t get subsidies. I doubt that getting an individual plan would be of benefit for you.
  • I have a toddler.  She was covered under my employer plan from birth (Sharp plan) I am no longer working for the employer and coverage ended october 31, 2017.  We have coverage through covered california (Sharp plan) since november 1, 2017.  I have custodial custody.  Her father decided to add her to his employer health plan during open enrollment in October 2017 to take effect January 1, 2018 (Kaiser plan). He did not tell kaiser my daighter [daughter] has coverage with sharp.  Is it illegal for my daughter to have dual health insurance when she is covered under covered california?   If not, is there not a conflict when it’s two different providers?  What are the legal code/rules in determining who’s insurance is primary?
    • Check out page on dual coverage for more information on determining which plan is primary and how they co-ordinate coverage. If you have more questions on dual coverage, please ask on that page.
    • Please note that we can be your agent with Covered CA at no additional charge to you. Here’s instructions to make that change. Covered CA is not paying me a salary to help people. I only get paid when I’m appointed as an agent. I do not get paid at all to help people with Medi-Cal.
    • There is generally no problem with having Covered CA and another plan.
    • The problem you have here though is that your daughter is eligible for an employer plan at less than 9.66% of employee income.
    • So, if you were to pay full price – no subsidies for the Sharp Plan, you would be OK.
    • You are mandated to report this change to Covered CA within 30 days.
    • I’m not a family law attorney nor have I read your Marital Settlement Agreement. I don’t see that your having custody is an issue. There may well be a health insurance order mandating your husband to put your daughter on his insuranace if the premium is reasonable.
    • When you appoint us as your agent, we can help you with doing what you want on your daughters coverage and keeping the subsidies for the rest of your family.
    • If the Company you worked at got bought out by an other company, and your status changes from contractor to full time employee, are you still eligible for Medical if you can’t afford the premiums or out of pocket insurance plans they offer using your annual income? My position is outside sales, with a home office, now I am having even more expenses than before, due to the new company’s contract. I can not afford what they offer in regards to healthcare coverage.
    • We will answer your question on our MAGI Income page.
  • We are sort of confused. Currently we have medi-cal, and we are able to purchase HMO medical coverage from employer to have access to more providers than one or two medi-cal provides for the whole county.  We are suppose to go to the HMO provider first and paid the deductible, which is quite high, or can we decide which provider to go to base on our needs?  If we are required to go to the HMO providers first, which most of them doesn’t accept medi-cal, then we are forced to pay all the copay and deductible.  If we don’t want to pay anything, then we need to find a provider that accepts medi-cal AND is in our HMO network so it can bill both the private insurance and medi-cal so we don’t have to pay anything?  Basically, if we want better access to providers then we use our HMO, and pay for each visit, or go to the limited medi-cal providers and pay nothing, expect the monthly premium for the HMO.?
    • Excellent Question. I do not see any problem with going to whichever plan fits your needs at the time you choose service. While the Employer HMO would pay first, that’s only if it’s obligated to, that is you went to a network provider. Coordination of benefit rules apply if two or more policies are collectible…
    • I’m not a salaried Medi-Cal eligibility worker, you should double check.
    • Here’s more research: This is one of the frustrations that I have in the Medicare – Medi-Cal market and if it’s “proper” for me to sell HMO MAPD Medicare Advantage Plans to those on Medi-Cal, Cal-Medi Connect.
    • To answer your question with “Full Authority” I would have to see the dual coverage – co-ordination clauses in your Medi-Cal HMO and the Employer Group Plan HMO.
    • Here’s the Blue Cross Medicare Coordination Plan see pages 40 – 42
    • You are correct, if you use the employer HMO plan, they don’t pay for non network providers.
    • See Chapter 1 Section 10 Follow the links and find your evidence of coverage. Health Net asks you to call them at 1 800 675 6110 so that they can co-ordinate benefits.  Blue Cross Employer HMO on Page 105 spells out Coordination of Benefits and only appears at first read to apply to Medicare or other group plans.  Please see the reporting requirements to Medi-Cal on page 8 of Medi-Cal, what it means to you.  Excerpt from Western Poverty Law  Individuals with other health coverage may be eligible for Medi-Cal, but they must apply for and use other health coverage that they have or that is available to them.54 Medi-Cal beneficiaries who are enrolled in managed care are also subject to this requirement due to current contracting provisions,55 which can make coordination difficult between the Medi-Cal managed care plan and the other health coverage plan.
    • California is obligated to seek other sources of health coverage and to collect payment from liable third parties.56 This is mainly for coverage that is available at no charge.  
  • So much “fine prints” to read and understand! All we want is have more and easier access to specialist than then few med-cal specialist available in our county.   For primary care it really doesn’t matter which provider we go to because it is all covered by HMO or medi-cal.  For specialist we will just have to decided which provider to go base on the service that we need.  What about prescription? I assume it’s the same?
    • I know it’s a lot of fine print. I don’t even get paid to help people with Medi-Cal! Covered CA wants me to “facilitate” enrollment. By primary care, do you mean preventative care? I would think Rx is the same too. Using some of the contacts I have a Medi-Cal, I did ask them for some enlightenment.
    • I asked one of my clients who has a Blue Shield PPO and Medi-Cal about how the two plans work. Here’s an excerpt of her response:
    • I can’t respond because my daughter doesn’t have an HMO. She has a PPO. When I read the above, it seemed to cover it pretty well.   Her Medi-Cal benefits only seem to apply to drugs that are not covered by Blue Shield. Otherwise, it all goes through Blue Shield.
  • 1 I have a kid and she is eligible for MAGI Medi-Cal. 2 And I have applied for it and she has it active now.  3 And I purchased UNSUBSIDIZED private insurance ONLY for my kid through Covered California. 4 For some reason, I need both Medi-Cal and private insurance.  5 I did not apply insurance for my own. 6 Can my kid have both Medi-Cal and unsubsidized private insurance purchased from Covered California?
    • 3. I wasn’t aware that one could get unsubsidized coverage from Covered CA when qualified for Medi-Cal. I guess you applied for Medi-Cal direct though your county agency and not Covered CA, right? When you applied for Covered CA, you did not ask for subsidies?
    • 4. Why do you need both?
    • 5. Do you mean for yourself? You only have coverage for your daughter? You can get free no obligation quotes by clicking here.
    • If your daughter qualifies for Medi-Cal, you would likely qualify for major subsidies. This might be a problem, as when you list dependents, so that your Federal Poverty Level is lower, then Covered CA will let Medi-Cal know. This might mess up the private insurance you have through Covered CA. You could still purchase private coverage during open enrollment directly through an insurance company, with us as your agent, no charge.
    • 6. Yes. See above though about getting coverage for yourself. What good is her having coverage, if G-d forbid you get sick and can’t take care of her or pay your own medical bills. See the webpage above how private insurance co-ordinates with Medi-Cal.
      • 1 Yes you’re right. I don’t know how my agent worked on the application in Covered California.
      • 2 I applied through Covered California with agent’s help. My income is eligible for Medi-Cal. But I did not know that at first.
      • 3 Anyway, my application (for my kid only) was sent to Medi-Cal review automatically and it was approved.
      • 4 I also purchase unsubsidized health plan through CC with full payment for my kid only.
      • 5 I still don’t know how my agent could do this with putting income information in it.
      • 6 Because, I wanted to have both [Medi-Cal & Private) . I went to Medi-Cal office and the worker told me I can have both if I want.
      • 7 But, few days later, my health plan (unsubsidized plan) was canceled automatically due to Medi-Cal eligibility.
      • 8 I just found out yesterday.
      • 9 My kid has severe illness and I just need both Medi-Cal and private insurance. (let’s say it is just for my preference)
      • 10 Anyway, now… my kid has Medi-Cal active. but I still want private insurance, [for the kid] . (dual coverage).
      • 11 Then can I purchase private insurance outside of CC now?
      • 12 And can have both, Medi-Cal and private insurance?
        • 11 & 12 Yes. Click here for quotes & enroll.
        • What about coverage for yourself? Did you enroll in Medi-Cal? This is MAGI Medi-Cal. (eligible for only child)

 

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Medicare Dual Coverage Pamphlet

Our Webpage on Medicare & Dual Coverage 

Coordination of benefits -
two or more insurance plans
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#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