Medicare + Medi-Cal:
Which Doctors Can I See, and Can They Bill Me?

If you have both Medicare and Medi-Cal, two different questions matter:

Can you see this doctor or use this hospital?
- That depends mainly on whether you have Original Medicare or a Medicare Advantage plan, such as a D-SNP.
Can the provider charge you Medicare’s deductible, copayment, or 20% coinsurance?
- For Medicare-covered care, California generally protects people with Medicare and Medi-Cal from these charges.

This page explains the difference, what to say when an office tells you “we don’t take Medi-Cal,” and what to do if you receive a bill.

See my web page — Medicare, Medi-Cal, and other dual coverage.
California DHCS — The Facts on Balance Billing.

First, Which Kind of Medicare Do You Have?

Original Medicare + Medi-Cal:
- You can generally use a Medicare doctor or hospital willing to see you, even if the provider does not take Medi-Cal or belong to your Medi-Cal plan’s network.
- The provider still may decline to take you as a patient.
Original Medicare + a Medigap policy:
- There generally is no Medigap doctor network. Your provider must accept Medicare; your Medigap policy pays according to its benefits.
Medicare Advantage, including a D-SNP or Medi-Medi Plan:
- Check the Medicare Advantage plan’s provider network and rules before arranging routine care.
- Having Medi-Cal does not, by itself, let you bypass an HMO’s network.

See my web page — Original Medicare and Medigap versus Medicare Advantage.
California DHCS — Medi-Cal help: Medicare and provider questions.

Original Medicare + Medi-Cal:
Can I See a Doctor Who Does Not Take Medi-Cal?

Generally, yes—if the doctor accepts you as a Medicare patient and the service is covered by Medicare. California DHCS says you can use any Medicare provider willing to see you, even if that provider does not take Medi-Cal or is outside your Medi-Cal managed-care network.

When making an appointment, ask: “Do you accept Original Medicare, and are you accepting new Medicare patients?”
Tell the office you also have Medi-Cal, so it can record your secondary coverage and handle billing correctly.
For a service covered only by Medi-Cal, ask your Medi-Cal plan or county how to obtain that service. The Original Medicare doctor-choice rule does not automatically apply to Medi-Cal-only care.

Medicare — Find and compare Medicare providers.
California DHCS — Medi-Cal help: “Medicare or Medi-Cal providers”.

The Office Says, “We Don’t Take Medi-Cal.”
What Should I Say?

First ask: “Do you take Original Medicare?”
- If you have Original Medicare, explain that Medicare is your primary coverage for Medicare-covered care.
- A Medicare provider does not have to join your Medi-Cal managed-care network just to see you for Medicare-covered care.
Then explain: “I also have Medi-Cal as secondary coverage. Please enter both coverages and check the Medicare/Medi-Cal billing rules.”
If the office still declines the appointment:
- Ask whether it is declining all new Medicare patients or is concerned specifically about billing Medi-Cal.
- Ask its billing supervisor to review California DHCS’s balance-billing guidance.
- Remember that a provider generally can decide whether to accept you as a new patient.

Do not hide your Medi-Cal coverage. Showing both coverages helps the office process the claim and recognize the rules against billing you for Medicare cost sharing.

California DHCS — The Facts on Balance Billing.
Medicare — Medicare Savings Programs and showing your coverage cards.

Can the Doctor Charge Me Medicare’s 20%?

For a Medicare-covered service, a Medicare provider generally cannot bill a person with Medicare and Medi-Cal for Medicare’s deductible, copayment, or coinsurance. That includes the familiar Part B 20% and applicable Medicare Part A hospital cost sharing.

For example, Medicare processes a covered doctor visit and pays its share.
Medi-Cal then handles the Medicare cost-sharing portion under California’s payment rules.
Even if Medi-Cal pays the doctor little or nothing more, the doctor generally cannot turn around and collect the remaining Medicare cost sharing from you.
The same billing protection applies to Medicare-covered hospital care; it does not turn a service Medicare and Medi-Cal do not cover into a covered service.

This is sometimes called improper billing or balance billing. It can occur even when the Medicare provider is not enrolled in Medi-Cal.

California DHCS — The Facts on Balance Billing: doctors, hospitals, and crossover claims.

What Changes If I Have a D-SNP or Medi-Medi Plan?

A Dual Eligible Special Needs Plan (D-SNP) is a Medicare Advantage plan. A California Medi-Medi Plan coordinates Medicare and Medi-Cal benefits through a plan and its provider network.

For an HMO D-SNP:
- Use the plan’s network for routine care, subject to its referral and authorization rules.
- Emergency care, urgent care, and out-of-area dialysis have special network exceptions.
For a PPO D-SNP:
- Check the particular plan’s rules for care outside its network before making an appointment.
For covered care:
- Medicare/Medi-Cal billing protections still matter. If you receive a bill, ask the plan to review it.

Practical step: Before a non-emergency appointment, call the number on your D-SNP card and confirm that the doctor, facility, and service are covered under your specific plan.

California DHCS — Medi-Medi Plans.
Medicare — Compare Medicare Advantage plan types and network rules.

How Is Medigap Different from Medi-Cal?

Original Medicare + Medigap:
- You generally may use Medicare providers willing to see you.
- Your Medigap policy pays some or all Medicare cost sharing according to the specific policy.
- You pay the policy premium and any costs the policy does not cover.
Original Medicare + Medi-Cal:
- You generally may use Medicare providers willing to see you.
- For Medicare-covered services, the provider generally cannot bill you Medicare cost sharing, subject to the Share of Cost and other distinctions explained below.

Can someone have Medigap and Medi-Cal? This needs an individual review. Medicare says companies generally cannot sell a new Medigap policy to someone who has Medicaid. Someone who already has a policy, or whose Medi-Cal eligibility involves a Share of Cost, should review the actual coverage and eligibility before buying, dropping, or replacing anything.

See my web page — Medigap premiums and Medi-Cal Share of Cost.
Medicare — When you can buy a Medigap policy.

Are There Times I Might Have to Pay?

Yes. “They cannot bill me Medicare’s 20%” does not mean every possible charge is prohibited. California DHCS identifies these important exceptions:

Part D prescriptions: You may owe an applicable prescription copayment.
Medi-Cal Share of Cost: If you have a monthly Share of Cost that has not been met, ask how it applies before assuming the visit is free.
- See my web page — How Medi-Cal Share of Cost works and ways to reduce it.
- See my web page — Using medical expenses toward Share of Cost.
Services neither program covers: Ask about coverage and the price before receiving the service.
Certain administrative fees: A permissible fee for a missed appointment or a form completed outside a visit may be charged under applicable rules.

If you are unsure whether a bill is Medicare cost sharing, an unmet Share of Cost, or an uncovered service, request an itemized bill and an explanation before paying it.

California DHCS — The Facts on Balance Billing: exceptions.

I Received a Bill. What Should I Do?

Check what the charge is for.
- Ask for an itemized bill and check your Medicare Summary Notice or plan Explanation of Benefits.
- Is this Medicare cost sharing for covered care, a Part D copay, an unmet Medi-Cal Share of Cost, or a service that was not covered?
If it appears to be prohibited Medicare cost sharing, contact the provider’s billing office.
- Tell them you had Medicare and Medi-Cal on the date of service.
- Ask them to correct the account, stop collection, and refund any amount you already paid improperly.
- Send them the California DHCS balance-billing explanation.
If the office does not fix it:
- For Original Medicare, call 1-800-MEDICARE (1-800-633-4227).
- For Medicare Advantage or a D-SNP, contact your plan.
- For further help, contact the Medicare Medi-Cal Ombudsman at 1-855-501-3077.

Keep copies of the bill, your coverage cards, your explanation of benefits, and any letters or messages with the provider.

Detailed References & Related Pages

Official guidance

California DHCS — The Facts on Balance Billing: Medicare cost sharing, exceptions, crossover billing, and help with improper bills.
California DHCS — Medi-Cal Help: using a Medicare provider who does not take Medi-Cal.
California DHCS — Full and Partial Dual Eligibility: differences in Medi-Cal and Medicare Savings Program eligibility.
Medicare — Medicare Savings Programs: Qualified Medicare Beneficiary (QMB) billing protection and coverage cards.
Medicare — Compare Medicare Advantage plan types: HMO, PPO, and Special Needs Plan network rules.

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