If you have Medi-Cal and other insurance,
how much does each one pay?
Which pays first?

Private Health Insurance, Other Health Coverage (OHC)  and Medi-Cal

 

You can have Medi-Cal even though you have Other Health Coverage (OHC) through individual or group private health (or dental) insurance 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 page on child support  and   Health Insurance Court Orders.

Medi Cal Webpage to report other 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.

Medi-Cal will pay the maximum that they are allowed to!

Of course they will deduct the OHC payment amount, 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 MediCal 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.

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 coverageMedi-Cal What it Means to you”  Section 12 

Managed Care MCO and Third Party Liability TPL

The contract language between the State Medicaid – Medi Cal  agency and the Managed Care Organization (MCO) dictates the terms and conditions under which the MCO assumes TPL responsibility. Generally, TPL administration and performance activities that are the responsibility of the MCO will be set by the state and should be accompanied by state oversight.

There are four basic approaches to carrying out TPL Third Party Liability functions in a managed care environment.

Enrollees with other insurance coverage are enrolled in managed care and the state retains TPL responsibilities

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

Enrollees and/or their dependents with commercial managed care coverage are excluded from enrollment in Medicaid MCOs, while TPL for other enrollees with private health insurance or Medicare coverage is delegated to the MCO with the state retaining responsibility only for tort and estate recoveries  Medicaid.gov *

Our website is #MUCH more than just
Pro Bono helping you with Medi-Cal

We've developed the Medi-Cal portion of our website, as many of our Covered CA clients unfortunately end up here, if their income drops below 133% of FPL, Federal Poverty Level, see the income chart.

We do not get a nickel, for this site or for helping people enroll in Medi-Cal, nor answering complex questions.  When you have other questions or need coverage, take a look at   our other websites:

Try calling or searching the Insurance Company #HMOProviders  website that is handling your Medi-Cal

Be sure to find their EOC Evidence of Coverage to know exactly how your benefits work.

HMO – Managed Care Providers

Can you get Medi Cal
If you have other insurance?

 

Yes, you can still get Medi Cal if you qualify, even if you have other coverage.

If you have other health coverage you may be eligible for Medi-Cal, but you must  use  your other health coverage, first.

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.

 

HMO – Managed Care Providers vs. Fee-for-Service

Under managed care, the state contracts with health plans and pays a fixed amount each month per member enrolled in the plan. The HMO health plan is then responsible for providing all Medi-Cal services included under the contract. 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.

Under FFS, 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. CHFS.org *

Fee for Service Provider Directory?

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 *

Exceptions:

The Medi-Cal Access Program,

a separate program administered by DHCS, is only available to insured women whose insurance does not cover maternity services – I don’t think that applies anymore as Obamacare mandates maternity as an essential benefit.  or with maternity-only deductibles or co-payments greater than $500.

Federal Breast & Cervical Cancer Treatment Program

is only available to women with no other creditable coverage that covers her breast or cervical cancer treatment.  Women applying for the state-only Breast & Cervical Cancer Treatment Program (BCCTP) must be uninsured or underinsured.  Copied from Western Poverty Guide – Page 40 on dual coverage   

See also Women’s Health & Cancer rights act WHCRA

If you don't want Medi-Cal -

Can you buy private insurance?

If your income qualifies for Medi-Cal, you can buy Insurance coverage, 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.  Get quote here.  

 

Friendly Agent's Blog on how to have different plans for different members of the family.

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Video

Video understanding medicare advantage mapd

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.

That's why the premium is very low or ZERO!

Medicare Dual Coverage
# 02179
 
 

Medicare Dual Coverage Pamphlet

Our Webpage on Medicare & Dual Coverage 

Coordination of benefits -
two or more insurance plans
VIDEO 

Employer obligation to report # of employees to Medicare

Explanation from Cal Broker Magazine Sept 2019

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

Direct Phone # for Medi Cal
866.613.3777
Direct Phone # 866.613.3777

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82 comments on “Dual Coverage? Medi-Cal & Individual Private or Employer Plans?

  1. 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?

    Thank you for your time.

    • 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…

      Check back in a day or two… I’ll check with the Medi Cal ombudsman.

      • 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]

  2. 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?

    Thanks,
    Dan

  3. My three children have primary insurance through their fathers employer, and secondary medi-cal under a waiver program due to their disabilities.

    I’ve been told they must stay on FFS [Fee for Service] or straight medi-cal since they have primary, and cannot choose a managed care plan in our county (Alameda).

    They have ABA therapy with thousands of dollars of copay a month—straight medi-cal will not cover ABA therapy, but the managed care plan would.

    Is it correct we cannot choose a managed care plan since we have the primary insurance for them?

    • See the response from the Medi Cal Ombudsman below!

      If you wanted to opt out of HMO enrollment, here’s the form

      I don’t see why Medi Cal would not pay for ABA therapy. Mental Health is a mandated essential benefit.

      Autism is listed as a “severe mental illness” under CA AB 88

      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.

      Enrollees with any other insurance coverage are excluded from enrollment in managed care

      I’ll ask [email protected] if they can shed any light on this issue.

      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.

      • Here’s the reply excerpt from Medi-Cal, let me know if you want the full email. I’m just showing the NEW information, not what I already said above or the webpage above.

        If you have specific questions about Medi-Cal Managed Care, please contact the Office of the Ombudsman by phone at 1-888-452-8609 or by email at [email protected]

        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.

        I already told you about the exemption request – please click on the link above. IMHO from what you’ve said, you are not eligible for an exemption.

        I will check with the Ombudsman.

        • 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.

          The information provided is correct.

          Office of the Ombudsman 358
          Managed Care Operations Division
          Dept. of Health Care Services
          Phone: (888)452-8609
          Fax (916) 440-7438
          [email protected]

          • I have two kids with autism who qualified for Medi-Cal with the Regional Center income waiver program.

            I enrolled them in one of the Medical [sic] managed care plan and when I tried to use the plan for my kids ABA therapy it was denied.

            I called Medi-Cal managed care health care options and they told me my kids can only have straight medical.

            The problem I run into now is that I cannot find a provider who takes straight Medical.[sic] They will only take medi-cal managed care plans.

            I have to pay $7,000 in co-payments with my private insurance before any therapies or services are free.

            Also, I know that there are other families who have private insurance and are also enrolled in the managed care plan.

            My question is how can I get enrolled again so they can cover my co-pays? Do I have any other option?

            We cannot afford $7000 in co-payments every year.

            Thank you for any advice.

      • Reply from Blue Cross:

        Hi Steve,

        You will have to reach out to the State sponsored division that handles Medi Cal. We don’t have that information, and do not have contacts in that area.

        Please wait for them to respond to you.

  4. Hi,
    My family has private insurance through Covered California (healthnet).

    I 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.

    Thank you!

  5. 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?

    Please help.

  6. We’re a provider for ABA Applied Behavior Analysis services only (not a medical facility).

    A client has Medi-Cal as their secondary insurance and would like us to bill Medi-Cal; however, we are not contracted with Medi-Cal as of yet (we our contracted with Molina). So I have a couple of questions:

    1. Can I still bill Medi-Cal for services already rendered?
    2. Can the parent submit receipts to Medi-Cal for paid services on their own behalf for reimbursement?
    3. Is there a phone number of someone I can contact directly to help with questions such as these?

    Thank you in advance for your help.

  7. 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?

  8. My child has health insurance through her father’s employer and straight medi cal through my application for her and myself.

    I was told when picking up her medication that medi cal doesn’t cover copays.

    My daughter had 4 prescriptions to pick up so i had to pay out of pocket for them.

    I had to pick and choose since i was short on funds and paid $25 for 1 inhailer.

    Should medi cal of paid the copay since it what was not covered by the insurance?

    • We don’t like hearsay and we will research an authoritative answer for you.

      Here’s our page on what Medi Cal covers

      Things might get confusing as Medi Cal assigns you, if you don’t pick one to an HMO.

      So, let’s see for example what LA Care offers.

      http://www.lacare.org/members/welcome-la-care/member-documents/medi-cal

      http://www.lacare.org/sites/default/files/universal/Medi-Cal%20Member%20Handbook-English.pdf

      What your health plan covers
      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.

      L.A. Care offers these types of services:
      • Outpatient (ambulatory) services
      • Emergency services
      • Hospice and palliative care
      • Hospitalization
      • Maternity and newborn care
      • Prescription drugs
      • Rehabilitative and habilitative services and devices
      • Laboratory services
      • Preventive and wellness services and chronic disease management
      • Mental health services
      • Substance use disorder services
      • Pediatric services
      • Vision services
      • Non-emergency medical transportation (NEMT)
      • Non-medical transportation (NMT)
      • Long-term services and supports (LTSS)
      • Transgender Services
      Read each of the sections below to learn more about the services you can get.

      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. A group of doctors and pharmacists update this list.
      • Updating this list helps to make sure that the drugs on it are safe and work.
      • If your doctor thinks you need to take a drug that is not on this list, your doctor will
      need to call L.A. Care to ask for pre-approval before you get the drug.
      To find out if a drug is on the PDL or to get a copy of the formulary call 1-888-839-9909 (TTY: 711). You may also visit the L.A. Care website at http://www.lacare.org/members/member-services/pharmacy-services.

      Sometimes L.A. Care needs to approve a drug that the provider prescribed. L.A. Care will review and decide on these requests within 24 hours.
      • A pharmacist or hospital emergency room may give you a 72-hour emergency supply if they think
      you need it. L.A. Care will pay for the emergency supply.
      • If L.A. Care says no to the request, L.A. Care will send you a letter that lets you know why and what other drugs or treatments you can try.

      Pharmacies

      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.

      Check out our link above for Life Insurance

  9. I am a provider and I can’t seem to find out rates Medi-Cal will pay for Behavioral Health codes.

    Client has primary and this would be for their secondary.

    Here is one of the codes- H2019. Can you help?

    The Medi-Cal rates do not contain these codes so I called Medi-Cal where they told me they have the description of each code but not the rates and for me to call Medicare (Noridian Health Care Solutions) where they said Medicare does not cover these codes.

    I know that Medi-Cal covers but I can’t see to find rates for the codes we use. It’s for Behavioral health-ABA.

  10. I have primary health insurance through employment, but it is a high deductible and out of pocket plan.

    Will Medi-cal pay my primary health insurance out of pocket?

    • 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/

  11. When a person has MEDI-CAL and accident medical group insurance, in the event of an eligible accident under the group, who pays first

      • 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/

  12. 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?

  13. 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

      Use our site map above and we have a page where it says they do you have SSI you automatically get Medi-Cal

  14. When I call Medi-Cal to give them the proof of private insurance they tell me I have to call my local SSI office to give them my info and those good folks told me I have to call Medi-Cal.

    Who really can straighten this typical government back and forth?

  15. 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

  16. 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?

  17. Really Appreciate this update, can you make it so I receive an update sent in an email whenever there is a new article?

    • Our Medi-Cal website is Pro Bono, so we are not doing a whole lot of updates… In the lower right hand corner of the page if your on a desktop computer or just scroll down if your using a smartphone, just enter your email and you can subscribe. One problem is, that we use pages and not posts. Posts are what gets sent out…

  18. 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.

  19. 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.

  20. 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.

  21. 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?

        Thanks.

      • 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.

  22. 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?

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