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.
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 coverage) “Medi-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 *
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:
Be sure to find their EOC Evidence of Coverage to know exactly how your benefits work.
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 *
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.
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
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.
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!
Coordination of benefits -
two or more insurance plans
Explanation from Cal Broker Magazine Sept 2019
You're Medicare Advantage plan has the right and responsibility to collect - subrogate for covered Medicare services for which Medicare is not the primary payer.
According to CMS regulations at 42 CFR sections 422.108 and 423.462, Anthem MediBlue Access (PPO), as a Medicare Advantage organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws. Anthem MediBlue Access (PPO) Evidence of Coverage
- Medi Cal Explained CHCF
- 10 Essential Health Benefits
- Our Webpage onMedi Cal Benefits
- Western Poverty Law - Exact Legal Rules on Coverage for Low Income Californian's
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