Posted on April 15, 2026 by Steve Shorr — No Comments ↓

Medi Cal HMO Mandatory Selection!

Fee for Service rarely available option

Medi-Cal Managed Care HMO – Health Care Options

#Pick your Plan

Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.

Get a lot more detail & analysis on Medi Cal HMO providers see our webpage on that

While you can have an employer or Indivudaul Plan and Medi Cal, there is However a
#MANDATORY Medi Cal Managed Care – HMO health
Enrollment

One must choose a Managed Care – HMO health plan – provider within 30 days after enrollment in Medi-Cal otherwise the State will pick plan for you. ^{Medi-Cal Website} Unless you have Other Health Coverage -OHC, then you must go Fee for Service.

When you have an HMO managed health care, the State of California makes a deal with health plans and pays a fixed amount each month per member enrolled in the plan – capitation. The HMO health plan is then responsible for providing you all your Medi-Cal services included under the EOC Evidence of Coverage. HMO Plans are required under state and federal law to maintain an adequate Medi-Cal provider network to ensure that each member has a primary care physician and must report on quality and access measures.

Medi Cal Managed Care Find a Provider
See the email we rec’d May 17th from Medi Cal to clarify some of these issues
chcf.org/primary-care-matters * More readable summary * Health care systems with strong levels of primary care investment have better and more equitable health outcomes, lower care costs, and better care quality. We can build a healthier future for all Californians by focusing resources back to patients and their relationship with primary care providers.

#Clarification from Medi-Cal on
HMO Mandatory Enrollment and other coverage OHC

Hi Steve –

On May 8, you reached out to our Office of Communications, and requested answers to the following questions. Please see DHCS’ responses*** below.

What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?

On this DHCS page, the public is told they must choose an HMO. Nothing is said about if you have other coverage, it’s excluded. [not mentioned on the DHCS page?]

Medi-Cal managed care plans do not stop beneficiaries from enrolling in private health insurance plans. If a Medi-Cal beneficiary is currently enrolled in a Medi-Cal managed care plan, and subsequently purchases private health insurance, they will not be disenrolled from the Medi-Cal managed care plan.

The website above only applies to Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care plan, which is the large majority of the Medi-Cal population.

On or about 10.26.2020 the Medi Cal Ombudsman emailed and said that if one had private insurance they could NOT enroll in a Medi Cal Managed Care Plan!

If a Medi-Cal beneficiary has active other health coverage upon Medi-Cal enrollment, they are currently not eligible for enrollment into a managed care plan.

However, Medi-Cal beneficiaries with other health insurance will be eligible to enroll in a managed care plan after DHCS implements the California Advancing and Innovating Medi-Cal (CalAIM) initiative to transition share of cost beneficiaries to Medi-Cal managed care for non-duals (Medi-Cal coverage only) on January 1, 2022 and duals (Medicare and Medi-Cal coverage) in January 1, 2023.

When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?

A Medi-Cal beneficiary who has other health insurance (OHC) is required to exhaust their OHC before Medi-Cal assumes payment for a service. However, Medi-Cal providers are not allowed to deny a medically necessary service even if the provider has evidence that a beneficiary has OHC. In order for the provider to bill Medi-Cal for that service, the provider must first obtain a denial letter from the OHC entity. (Other Health Coverage (OHC) Guidelines for Billing (other guide) (ca.gov) pg1)

When a member uses HMO services, how does the HMO collect & bill other coverage?

Assuming that you are referring to “HMO” as a Medi-Cal managed care plan, the State has direct data exchanges with commercial health insurance carriers to identify members with other health coverage. This data is shared with Medi-Cal Managed Care Plans to ensure effective coordination of benefits. If other health coverage information is present at time of billing, the Medi-Cal managed care plan will reject (not deny) the claim and provide the other health coverage information to the provider for billing. If other health coverage information is obtained after a Medi-Cal managed care plan has paid for the claim, the plan will initiate post-payment recovery.

When a member uses say his Employer’s HMO or PPO how does the collect copays & deductibles from Medi Cal HMO and/or fee for service?

Medi-Cal managed care plans and Medi-Cal fee-for-service do not pay for a Medi-Cal beneficiary’s copays or deductibles for their employer’s HMO/PPO plan.

The DHCS Health Insurance Premium Payment program does offer an option for a narrow population of newly enrolled Medi-Cal beneficiaries to receive reimbursement for OHC co-pays and deductibles for a limited time, subject to eligibility requirements. Please see dhcs.ca.gov for additional information.

Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
is CA using?

How is this being enforced & implemented?

CA currently uses the two out of four approaches:

· Enrollees with any other insurance coverage are excluded from enrollment in managed care (note that this will change after Cal AIM implementation)

· Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments

o This approach is used when a Medi-Cal beneficiary is first enrolled in a Medi-Cal managed care plan and subsequently obtains other health coverage. TPL responsibilities are then delegated to the Medi-Cal managed care plan for the first 12 months after the date of payment for a service.

If you have any additional questions on other health coverage and Medi-Cal, please let me know.

Thank you!

Lindsey Wilson, Chief

Coordination of Benefits and Administration

Third Party Liability and Recovery Division

***Please note that a few things in the letter were changed, so that it would look better when posted on the web.

Contrast…

You cannot choose a medical HMO Managed Care plan if:

You are a member of a commercial medical plan through private insurance ^{Health Care Options DHCA.Gov} * ^response ^{from the Medi Cal Ombudsman}^{* Western Poverty Law Page 5.219} * ^Medicaid.gov *

You must take Fee for Service.

Request for exemption from enrollment in Managed Care Plan, but I don’t see OHC as a reason

IEHP Provider manual seems to imply their HMO will allow it?

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

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

Medi Cal HMO #Providers

Learn more:

Disability Rights.org –
What are Medi Cal Managed Care Plans? What do I need to know?
Medi-Cal Managed Care Health Plan Directory
Poor Care Co-Ordination? New contracting process Deficient Oversight ^{CA Health Line} *
Disability Rights – Medi Cal provider HMO’s, what are they? What do I need to know about them?
Medi-Cal Managed Care – Health Care Options
- Get forms
EOC’s, Forms & Income Charts from Insure Me Kevin.com
Sacramento? dhcs.ca.gov//mmcd health plan dir
Battle Lines Are Drawn Over California Deal With Kaiser Permanente
Exemption from enrolling in a Health Care Plan
- health care options.dhcs.ca.gov – Download Forms
- You May Get A Medical Exemption If:
  - You have a complex medical condition; AND
    - The care you get from your Regular Medi-Cal doctor for the complex medical condition cannot be changed, because your condition could get worse; AND
    - Your Regular Medi-Cal doctor is NOT part of a plan in your county. You may see more than one Regular Medi-Cal doctor. If you do, have the form filled out by the doctor who sees you most often. Ask your Regular Medi-Cal doctor if he or she is part of a Plan in your county. This should be done before you submit this form.
- Provider Search – Statewide Fee for Service
  - See our webpage on IMR Independent Medical Review
Medi Cal Explainers chcf.org/explainers

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. We can help you lower your share of cost with purchasing Dental, Vision & Medi Gap coverage. See our webpage on share of cost.

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} *

(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?

Health Care Options.CA.Gov
DHCS.CA.gov FAQ’s

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.
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]