Are you allowed to have OHC Other Health Insurance & Medi Cal at the Same time?
Yes, You can have Medi-Cal even though you have Other Health Coverage (OHC) through individual or group private health (or dental) insurance coverage.
How much does Medi Cal pay?
Medi-Cal Fee for Service will pay the maximum that they are allowed to!
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.
|Yes you can||No you can’t|
Who cannot enroll
You or a member of your family cannot choose a medical plan if:
You are a member of a commercial medical plan through private insurance Health Care Options DHCA.Gov *
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
according the the Medi Cal Ombudsman, if your son has other insurance, it’s primary and he would not qualify for a Medi Cal HMO. See FAQ’s for more information.
Your son would have to opt out of Medi Cal managed care and stay in fee for service. I’m not sure how that gets done as the only exemption form I could find health care options.dhcs.ca.gov/xemption doesn’t list having private coverage as a reason.
See Western Poverty Law Page 5.219 which also confirms that you don’t get to enroll in a Medi Cal HMO if you have other coverage!
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 PPO blue-shield/
IEHP .org/manuals Medi-Cal
MC_20F -Paragraph=D; quoted below:
“D. Other Health Coverage (OHC) Cost-Sharing Providers are prohibited from billing Medi-Cal recipients, or individuals active on their behalf, for any amounts other than the Medi-Cal copayment or Share of Cost (SOC).
Therefore, if the recipient’s OHC requires a copayment, coinsurance, deductible or other cost-sharing, the Provider is not permitted to bill the recipient.
If the Provider bills the OHC and the OHC denies or reduces payment because of its cost- sharing requirements, the Provider may then bill IEHP.”
Maybe IEHP thinks CA isn’t using Option 1 at the right column?
Managed Care Organization MCO and Third Party Liability TPB
There are four basic approaches to carrying out TPL functions in a managed care environment (HMO).
Do you have to tell or Report to Medi Cal that you have other 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.
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.
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.
What do I do if my other health plan sends a check to me?
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
HMO – Managed Care Providers vs. Fee-for-Service
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
What is Medi Cal Fee for Service?
FFS Fee for Service
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 *
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 *
- Medi Cal Explained CHCF
- 10 Essential Health Benefits
- Our Webpage on Medi & Denti Cal Benefits
- Western Poverty Law - Exact Legal Rules on Coverage for Low Income Californian's
Our Webpage on
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Videos on how great agents are
#MANDATORY Medi Cal Managed Care – HMO health
plans – providers
Under managed care, the state of California contracts 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 all Medi-Cal services included under the contract. 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 – Health Care Options – This Government Site allows you to review and choose the HMO that you want to deliver your Medi-Cal health Care. You can also visit the Insurance Company website, by scrolling down to the ones you’re interested in.
EOC’s, Forms & Income Charts from Insure Me Kevin.com
Medi Cal HMO – Managed Care Providers by County –
Enroll in Medi-Cal ONLINE – Los Angeles
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:
Historical Medi Cal Provider Issues
Litigation on Medi-Cal violating Judges order and putting people into HMO’s, rather than fee for service. CA Health Line 8.10.2017
Number of Medi-Cal Providers down by 25%
Paul Ryan – more and more MD’s just won’t take Medi-Cal – Medicaid Fact Checker Washington Post 2.1.2017
Many large physician groups no longer contract with health plans serving adult Medi-Cal patients, saying that government reimbursements are too low to cover the cost of treating patients.
For the typical office visit, Medi-Cal pays doctors only about a third of what their peers at federally qualified health centers receive, $150 on average. If the health centers’ fees exceed what insurers will pay, their administrators can bill the state for the residual amount. So, the state is forced by federal law to pay more for office visits at federally qualified health centers than it would have paid physicians in private hospital groups. Sacramento Bee 10.2.2017
The U.S. Supreme Court’s ruling October 2014 that private health care providers cannot file lawsuits against state Medicaid agencies over low reimbursement rates could limit future Medi-Cal lawsuits, the Los Angeles Times‘ “PolitiCal” reports. CA Health Line
Medi-Cal is California’s Medicaid program (Megerian, “PolitiCal,” Los Angeles Times, 3/31).
There are now about 11 million Medi-Cal beneficiaries, constituting nearly 30% of the state’s population
Under the Affordable Care Act, the federal government pays 100% of the costs for newly eligible Medi-Cal enrollees for the first three years. But the state is responsible for 50% of the costs for those who qualified for the program before the Obamacare expansion, even if they hadn’t previously enrolled
With payments of $18 to $24 a visit, “doctors can’t continue to accept new patients and keep their doors open,” said Molly Weedn, a spokeswoman for the California Medical Assn. Without enough doctors, Medi-Cal patients could continue landing in costly emergency rooms — the opposite of Obamacare’s aims.
There is application backlog of about 490,000 people,
California has already demonstrated to the rest of the country that it can dramatically cut its rate of uninsured, largely by increasing the size of Medi-Cal. Now it needs to show that its public insurance program can actually deliver the care its new enrollees are counting on. latimes.com
Money in CA budget to expand Medi-Cal but 10% reduction in payments to MD’s california health line.org
- Set up a phone, skype or face to face consultation
- Tools - Calculator to help you figure out how much you should get
Life Insurance Buyers Guide
How much life insurance you really need?
- Life Screening Form
- Set up a phone, Zoom, skype or face to face consultation
Benefits When You Have Coverage under More than One Plan
When Coordination of Benefits Applies
This coordination of benefits (COB) provision applies when a person has health care coverage under more than one Plan.
The order of benefit determination rules below govern the order in which each Plan will pay a claim for benefits.
The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses.
The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense. §1300.67.13 * UHC EOC
References & Links
model laws 50 pages drafted by the National Association of Insurance Commissioners (NAIC)
Health Care Reform Dependent Coverage vs Spousal Coverage
How about an HSA (Health Savings Account) rather than buying extra policies?
With COBRA protections and HIPAA availability when you lose Group Insurance, it probably is no longer necessary to keep an individual plan, “just in case.” The extra premium, would probably be better spent on Life or Disability Insurance.
Life Insurance does not have a co-ordination of benefits clause. They will ask on the application though if you have other coverage to prevent over insurance and to make sure there is insurable interest.
See also Balance Billing
What if your doctor charges more than the negotiated rate?
Subrogation if you get in an accident and someone else can be sued
- Read the Statute – Policy
- Read the Statute – Policy
- Read the Statute – Policy
- Then when you think you understand it, read it again
Our webpage on
- Plain English Rule, jiggery pokery and contract interpretation
- Evidence of Coverage EOC
- Plain Meaning Rule - How to read Policy - Contract
We’ve also included the relevant pamphlets from Medicare.
- Dual Coverage # 02179
- Medicare as Secondary Payer
- Medicare website,
- Medicare’s Subrogation Right to collect from other insurance
I have Medicare and:
- I have Medicaid.
- I’m 65 or older and have group health plan coverage based on my current employment (or the current employment of a spouse of any age), and my employer has 20 or more employees.
- I’m under 65, entitled to Medicare because I have a disability (other than ESRD), I’m covered by a large group health plan because I or a family member is still working.
- I work for a small company that has a group health plan.
- I have a domestic partner with group health insurance coverage.
- I have declined or dropped employer-offered coverage.
- I’m retired, 65 or older and have group health plan coverage from my former employer.
- I’m retired, under 65 and disabled (other than by ESRD), and have group health plan coverage from my former employer.
- I have COBRA continuation coverage.
- I’m in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first. Who pays first if I go outside the employer plan’s network?
- I get health care services from the Indian Health Service.
- I have more than one other type of insurance or coverage.
- I have TRICARE.
- I have Veterans’ benefits
- I have ESRD and group health plan coverage.
- I have coverage under the Federal Black Lung Program.
- I have a claim for no-fault or liability insurance.
- I filed a workers’ compensation claim.
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
Benefits Coordination & Recovery Center (BCRC)—
The company that acts on behalf of Medicare to collect and manage information on other types of insurance or coverage that a person with Medicare may have, and determine whether the coverage pays before or after Medicare. This company also acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary
Medicare Secondary Payer Manual
My Care, My Choice helps people who have both Medicare and Medi-Cal explore health care coverage choices based on their location, their needs, and what they want from their coverage.
Unlike other websites, MyCareMyChoice.org isn’t run by a health plan or broker, and it doesn’t sell any products. But it’s funded by SCAN.
Our goal is simple: helping Californians with Medicare + Medi-Cal learn about their coverage options so they can make the best choice based on their unique needs.
The Advisor Tools page is designed to help the advocates, family members, caregivers, and service providers who help people with Medicare and Medi-Cal make health care decisions.
Some Cal Medi Medicare MMP Default Plans:
CalDuals is a website to support California’s Dual Eligible Population. Here you will find information about Medicare and Medi-Cal integration through the Coordinated Care Initiative, or CCI. The CCI was launched by the state of California to provide better coordinated care to people with both Medicare and Medi-Cal – dual eligibles.
Cedars Sinai Tool & Information – How to OPT OUT! Also applies EVEN if you don’t use their facilities!
dhcs.ca.gov Technical Page on Cal Medi-Connect Demonstration
Health Care Options 844.580.7272 – State Enrollment Broker – Enroll & Dis-enroll
HICAP – CA Health Care Advocates – 1-800-434-0222
See our Medi Cal Page
DHCS.Gov Medi-Cal Managed Care
ca health advocates.org (Medi-Cal)
LIS – Low Income Subsidy (Medicare Part D Rx – Help with Drug Costs)
InsureMeKevin.com on Blue Cross SNP & Dual Eligibility with Medi-Cal
Justice in Aging duals demo advocacy.org/
How to Opt Out of Cal Medi Connect