If you have Medi-Cal, Medicare, Individual, Employer Group and OHC Other Health Insurance,
how much does each one pay?
Which pays first?
Can you still pick which doctor and hospital you go to?

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! 

Here’s our webpage on what Full Scope Medi Cal 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.

For Medi Cal HMO’s check out each one’s summary of benefits and EOC’s Explanation of Benefits.

 

Can you #have a Medi Cal HMO if you have OHC Other Health Coverage?

 

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

 

20 – Claims Processing (PDF)

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).

  1. Enrollees with any other insurance coverage are excluded from enrollment in managed care
  2. Enrollees with other insurance coverage are enrolled in managed care and the state retains TPL responsibilities
  3. 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
  4. 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 *
     
     
     
     

 

 

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.

See our page on child support  and   Health Insurance Court Orders.

Medi Cal Webpage to report other coverage

Which Insurance Plan pays #first?

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 coverageMedi-Cal What it Means to you”  Section 12 

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

HMO

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

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 *

 

 

#MANDATORY Medi Cal Managed Care – HMO health
plans – providers

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  

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.

Medi Cal Provider HMO Selection Website

learn choose enroll medi cal plans

Disability Rights.org  – What are Medi Cal Managed Care Plans?  What do I need to know?

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:

Historical Medi Cal Provider Issues

54% of MD’s accept Medi-Cal  4.3.2015

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% californiahealthline.org/2014/7/15

Paul Ryan – more and more MD’s just won’t take Medi-Cal – Medicaid Fact Checker Washington Post 2.1.2017

Video on problems finding doctors

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).

Los Angeles Times 8.14.2014 – Few Providers, etc

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

Get Instant Term Life Quote

get term life quotes

Life Insurance Buyers Guide

NAIC Life Insurance Buyers Guide

How much  life insurance you really need?

Video Insurance Unnecessary Cost?

Basic Law & Rules on #Coordination of Benefits

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)

Simple explanation of how Co Ordination of benefits works – Financial Web

Illinois.gov – Simple Explanation with charts

More Explanations of #COB Coordination of Benefits

Delta Dentals Explanation

“Working Spouse Rule”

Health Care Reform Dependent Coverage vs Spousal Coverage

How about an HSA (Health Savings Account) rather than buying extra policies?

There might be some cases where a COB provision is not allowed – like HIPAA policies for when COBRA ends.


Individual Plans
 cannot  have this clause per CCR California Code of Regulations 1300.67.13 BUT, they might require that you cancel other coverage.  Blue Cross EOC Page 5

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?

Technical Resources

Subrogation if you get in an accident and someone else can be sued

CA Insurance Code §10270.98  Group Health Insurance Co-Ordination of Benefits

How are claims paid if you have #Medicare &
Other Insurance?


Dual Coverage?

If you have questions about how Medicare works with other coverage, you’ve come to the right page.  Hopefully, we’ve or our links will answer all your questions on  dual coverage here.

We’ve also included the relevant pamphlets from Medicare.

I have Medicare and:

If you still have questions,  email us, * set a meeting, * ask us a question right on this page, you don’t have to even leave your name.

#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

Medicare Secondary Payer Recovery Process
Click to Enlarge 

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

1-855-798-2627.

Coordination of Benefits & Recovery Overview

Beneficiary Services  

Contact Page

Cal Medi #Connect program

D SNP – Dual Eligible Special Needs Plans

Medi Medi – Medicare & Medi-Cal Plan (MMP – Dual Eligible)

Can you choose your own  Medicare Advantage Plan & Medi-Cal HMO or one will be chosen for  you?

  • Option A Medicare & Medi-Cal in ONE plan (Los Angeles Options)
  • Option B Keep Medicare (Get an Advantage Plan or Medi Gap?) and get a Medi-Cal Plan (Los Angeles) Cal Duals.org Cedars Sinai
logo my care my choice

 

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.

Cal Optima Logo

health plans participating in cal medi Connect

Consumer Links

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.  

Health Net Blue Cross

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

Medi-Cal Providers

Provider List by County

Los Angeles Times 2.1.2015 Problems with shifting care for costly patients

DHCS.Gov Medi-Cal Managed Care

ca health advocates.org (Medi-Cal)

LIS – Low Income Subsidy (Medicare Part D Rx – Help with Drug Costs)

Doctor’s can’t bill Medi Medi patients for Co Pays, Deductibles, etc.

InsureMeKevin.com on Blue Cross SNP & Dual Eligibility with Medi-Cal

Fraud, Waste & Abuse

Justice in Aging duals demo advocacy.org/

Technical Links

SB 1008 and SB 1036

CMS Reporting Requirements and other technical stuff

Dual Eligible Performance Studies – Inovalon

Needs assessment checklist

Problems with Medi-Medi – unwitting Guinea Pigs real clear policy.com

88 comments on “Dual Coverage? Medi Cal, Employer Group, Individual, Cal Medi Connect & Medicare

  1. 7 comments on “HMO – Managed Care Providers”

    1. Teri L says:

      Stanford Medical told me I would have to drop my Medi-Cal to get their full financial assistance (charity care)?

      I was told that I could not come to Stanford for any health care if I was a Medi-Cal recipient……… because then Stanford would be commiting FRAUD. I was told I would have to ‘quit’ my Medi-Cal or get the permission from Kaiser (who I have for my Medical-Cal) to see a ‘out of network’ surgeon…….

      How do I opt out of Medi-Cal?

      If I quit or gave up my Medi-cal , will I be able to reinstate it or reapply when I am ready…assuming I still qualify/?

      Reply
      • Anonymous says:

        I could spend on private insurance to at least see the doctor of my choice if not be treated by him.

        I know little about how PPO plans work…could I literally buy an $800 a month plan just long enough to consult with Dr. xx?

        Continue it just long enough just to be treated? Or would there be contracts and delays?

        I’m also concerned Cedars might refuse to give me an appointment without the medi-cal being fully cancelled.

        I’m willing to cancel it but again there could be delays from state documenting cancellation.

        Reply
    2. Anonymous says:

      HELP!!!

      I have blood in my stool. Medi-Cal won’t let me have a colonoscopy for 3 months.

      What can I do to get an appointment sooner?

      Reply
  2. Our son is on Medi-Cal in LA County; will be moving to Berkeley (Alameda County?) in August.

    Will he lose his Medi-Cal coverage if he signs up for SHIP…or more accurately, does not opt out of SHIP?

    He is not our dependent and is over age 26…on Medi-cal for more than three years.

  3. I am in a dilemma,

    1 I didn’t know I was approved for Medi – CAL (California) until I was taken to the emergency room (there were several bills, one for the facility, one for services rendered, and one for the doctor in the ER) visit unconscious.

    2 I didn’t know I had any bills because I have TRICARE SELECT, US Military. I was under the impression Tricare was taking care of the bills.

    3 I recently received calls that were being blocked by ROBOCALLER. Once I unblocked it I realized that the hospital billing was actually not a bad idea to figure out. Around $15k and I am still dealing with it.

    4 My social security # and my address were incorrectly put in by the hospital. (and probably by good reason due to my head injury).

    5 Where do I start, I am updating with TRICARE SELECT. as we speak.

    6 But to be honest, I don’t even think I should have been approved for MEDI-CAL. I have tried to reach out to the local office where I had applied online for food benefits, still waiting on that response after 14 emails, no calls are answered, and I have no idea what to do there.

    7 If so, and I leave the past approval of the Medi Cal in place, who is responsible for this bill? First payer and who is the second payer?

    8 I realize it is out of the timeframe to file with Medi-CAL but the hospital didn’t have my information on file correctly, I never received a bill either nor was it ever to mind because I had a head injury. It was after 3 different companies, all being “bad collection” systems one lady finally said my social out loud. It was off by one digit. Updating that with the hospital now to.

    9 It came from the White House that insurance companies have to consider the Pandemic, does that pertain to Medi-CAL?

  4. Letter to almost all Insurance Companies, Medi Cal, Department of Insurance & Managed Health Care

    Gentlemen,

     

    My Pro Bono website on Medi Cal is # 1 in Google for the questions on what if you have Medi Cal and other insurance.   I find it quite confusing and conflicting to give and get the authoritative correct answers.

     

    Would you please answer these questions, with citations to CA or Federal Law, Regulations, Evidence of Coverage, whatever.  I don’t like posting hearsay evidence, so and so said.

     

    1. What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?
      1. 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.
      2. 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!
    2. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?
    3. When a member uses HMO services, how does the HMO collect & bill other coverage?
    4. 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?
    5. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which is CA using?
      1. How is this being enforced & implemented?

     

    I’m not getting a penny in compensation from Covered CA nor any Insurance Company for my website.   IMHO the least you can do, is give me the correct answers for posting.

     

    I will be posting this email on my website.  Please respond for the public there.  I’m doing all this, not getting a penny, even for website expenses.  IMHO the least Medi Cal and the Insurance Companies who are making $$$ from my taxes and website information is respond with an authoritative and correct answer.

     

    Steve

  5. 3 comments on “Medicare – Dual Coverage – Subrogation”

    1. Anonymous says:

      I’m turning 65 and I have an individual plan that doesn’t have a co-ordination of benefits clause along with a Covered CA plan. I’ve been able to collect twice as the individual plan doesn’t have a co-ordination of benefits clause.

      I’m turning 65, it appears that my individual plan, won’t duplicate benefits with Medicare.

      Does that mean I can’t collect twice? Can I collect up to 100%?

      Medicare Duplicate

      Reply
      • Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).

        Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate paymentsCMS.gov

        noun: duplicate; plural noun: duplicates
        /ˈd(y)o͞opləkət/Submit
        1.
        one of two or more identical things.
        “books may be disposed of if they are duplicates” Google

        Reply
    2. Dual Coverage Questions from a website visitor 
      Answered in Interlineation

      My wife (I have full authorization filed for disclosure) is 69 and coverage by traditional Medicare (A and B) and also has group health insurance under a group of less than 20 employees.

      ***Thus Medicare pays first.

      She had an accident and fractured her teeth requiring implant and new porcelain/ceramic pontics.

      ***Thus Medicare would pay for an accident, but not routine dental.

      Claims were submitted to BCBS of Florida who says we should have first submitted the claim to Medicare.

      ***That’s correct, as Medicare pays first, then your group plan picks up the rest.

      I have already paid directly for the services.

      We reside in Florida and there were two D.M.D.’s (Doctor of Dental Medicine – same as DDS) involved in providing the services.

      What do you recommend?

      ***I suggest that you just send the bill to Medicare.  Then resend to your group plan, once Medicare has paid.

      (Also, when we look at my wife’s profile online

      ***Do you mean her Medicare profile? http://www.MyMedicare.Gov?

      it doesn’t list the supplemental carrier at all. How to we correct that?

      ***Send me your password privately and I’ll figure it out.  Medicare also has a customer service and live chat on the website.  They should be able to help you.

  6. 36 comments on “Dual Coverage – NOT Medi Cal – Who pays 1st? Collect Twice? Individual Plans”

    1. Anonymous says:

      Primary vs Secondary in emergency

      We cover adult employed daughter under age 26- she received coverage from her new employer November 1.

      On November 14 she was in a bad accident and required emergency care. She gave her Blue Shield information. Her injury and subsequent care have been extensive including emergency spinal surgery in December.

      We just received notice from Blue Shield that effective November 1 Kaiser was primary and should be paying the costs.

      What are our rights in this case?

      The notices from Blue Shield are addressed to us as she is the dependent.

      Reply
      • We need to see the letter you got from Blue Shield. We are not allowed to accept hearsay.

        M. “Primary plan” means a plan whose benefits for a person’s health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:

        (1) The plan either has no order of benefit determination rules, or its rules differ from those permitted by this regulation; or
        (2) All plans that cover the person use the order of benefit determination rules required by this
        regulation, and under those rules the plan determines its benefits first. NAIC Model Rules

        So, if you don’t go to Kaiser they won’t pay. Thus, Blue Shield will pay at a non kaiser facility.

        Do NOT take this answer to the bank. We need the letter and your EOC’s Evidence of Coverage. If you don’t have ready access to your EOC, give us the exact name of your plan, we probably have access to them.

        FYI, Medi Cal doesn’t allow one to get an HMO if other coverage is available!

        Kaiser Group Information

        Blue Shield Individual & Family Information

        Our webpage on reading Insurance Policies and the Law – Read 3 times, then when you think you understand it, read again.

        • Lisa G says:

          Thanks for your response!

          The letter that my husband received from Blue Shield, after looking more carefully this morning, are actually copies for his information that were sent to the health care facilities and the hospital where she was taken. The letters tell the facilities that they should be billing Kaiser.

          If you’d like a copy to see what it says, please let me know how to get it to you, or if you’d just like the transcript here.

          Also, the coverage we have had for a few decades is Blue Shield of CA, HMO.

          • My email is encrypted coming and going by http://www.Paubox.com or you can upload to https://www.paubox.com/steveshorr/upload

            I need an EXACT name of the plan that you have with Blue Shield and your daughter has with Kaiser. If it’s an individual plan, it might not be allowed to have a co-ordination of benefits clause, see webpage above for citation.

            Since your daughter was in the hospital for an emergency, Kaiser would probably have to pay for it, even if not in their facility.

            Please advise exact name of plan. The EOC is 10 times easier to review, than trying to piece together all of the various laws and statutes.

            • Lisa G says:

              I just sent a copy of the letter to the link you provided. And the name of the insurance we carry is Blue Shield HMO, Pomona Valley Medical Group Inc. DBA, Pro Med Health Network A+… Does that help?

              • Steve Shorr says:

                No, I need the exact name of the plan or your EOC. Please visit the links above for our Group and Individual Blue Cross pages. It’s my understanding from above that there is no co-ordination of benefits on an individual plan.

                Rather than spend hours researching the law, pro bono, the answer is in your EOC.

                How about sending a copy of your ID card?

              • Here’s the relevant portion of the letter from Blue Shield to the hospital.

                subrogation letter

                • This is just a routine letter from Blue Shield letting the hospital know that under the rules for Coordination of benefits, Kaiser is supposed to pay first. If there is any portion of the bill that Kaiser doesn’t pay, then Blue Shield will pay up to their limits. It looks all routine to me.

                  I believe your concern is that you think that Blue Shield is saying you HAVE TO GO TO KAISER and not Blue Shield. There is nothing in the letter that says that.

                  I’m sure if you send me the EOC’s there is nothing there that says that.

                  Go to whatever MD you want, as long as they are on Blue Shields or Kaiser’s list.

                  Reply
                  • Lisa G says:

                    It seems to be quite tricky to actually FIND our EOC docs! My husband has sent and email to his HR department because the Blue Shield member page tells us “we may not be able to access” all the documents, and it seems the EOC is one of them? Is there a way around this if his HR department doesn’t come through?

                    Reply
                    • Go to our Blue Shield Employer Plan administrative Webpage

                      Then click on the forms image
                      forms

                      Watch Loom Video for more details

                      No one is telling you that your daughter must go to Kaiser, right? So, why worry? What difference does it make which plan pays first for the emergency care? The 2nd plan will pay after the first one does.

                      Normally, we do NOT deal with 3rd parties for competent adults. If you are going to ask more questions, we need you to “certify” that your daughter is too severely injured to handle this on her own.

                      Here’s where we enrolled a woman in Covered CA who had been in a major accident with her parents. When she got better we were accused of Fraud, etc. as she qualified for Medi Cal. Comment 1 ** 2

                      Reply
            • Lisa G says:

              Forgot to add… we literally have no record of the Kaiser plan. It was provide through a small organization in northern California called Animal Place. I believe it’s small group insurance in that case. Nothing fancy…

              Reply
              • Try asking your daughters employer. Kaiser has dozens of different offerings. I’ll grant that their group plans may all have the same co-ordination of benefits… but why gues? Just let me know the exact plan, then we can review the EOC.

                Reply
            • Lisa G says:

              I just sent the Blue Shield EOC.
              Please advise on where to look for information related to this case.
              Thanks so much!

              Reply
                • Lisa G says:

                  Thanks so much Steve – your information thus far has been amazing for us! The video was awesome and if we need further help, I’ll surely reach out to you!
                  Thanks again!

                  Reply
    2. This is a cut and paste from a prior Q & A to consolidate our website

      What are the rules with dual coverage in regards to
      COBRA for the husband & a group plan for wife?

      The Primary (person A)

      ***[How do I know, who is primary? I need to see the documents]

      If you are covered as an employee, member or subscriber under more than one plan, but are covered under state or federal continuation (COBRA) under one of the plans, then:

      The plan covering you as an employee, member or subscriber is primary over the plan covering you under state or federal continuation (COBRA). illinois.gov

      has health insurance through their job, loses job, continues COBRA coverage for the family, meets the maximum deductible of $4000, [individual and/or family deductible] they have 0% out of pocket expenses now except for the monthly premium of $1,442.

      Mid-year the spouse (person B) now gets a job with health insurance coverage through their employer.

      The premium is much less $338, deductible of $3,000 with 80% coverage for in-network.

      If they cancel the COBRA, then they pay a new deductible +20% of medical charges incurred. If they overlap and have dual-coverage, then they are really paying extra money for the second medical plan $338/month with little benefit

      ***I don’t quite follow, sounds like more benefit

      -since they’ve met their deductible and pay 0% out of pocket.

      What if the family has dual coverage for 1 month, then after the second month they cancel COBRA?

      Do they still have to meet the new deductible of $3,000?

      ***I’d have to see the new policy. I doubt there is any take over provision.  Thus, yes.

      Does the insurance company only look at charges that have occurred within that month of dual coverage in order to determine if deductible B $3,000 has been met?

      ***Deciding what medical bills go to the deductible has nothing to do with having other coverage.

      How do they determine when it’s beneficial to have dual coverage?

      ***The Insurance Company doesn’t decide if it’s better for you. That’s your decision. Why pay $1,442 to have dual coverage? In two months, you have the $3k deductible taken care of.  Also, the $338 contribution as the employer is paying the rest of the premium, is probably tax deductible, if the employer has set up a Section 125 POP Plan.

      Reply
    3. This is a cut & paste of a question we had on another page. We are putting it here, to better consolidate our website and put everything in a more logical order.

      The links and formatting get lost in the cut and paste. Just use our search engine at the top, when you need more detail on any of the technical terms.

      I have pretty good Cobra Insurance (Health Net PPO, eligibility expires 12/17), however, I am concerned with the current political climate, Obama Care may go away

      ***Here’s where I’m keeping up on the status. donaldcare.healthreformquotes.com

      and when I am no longer eligible for Cobra, it might be difficult to get insurance due to pre-existing condition or other medical related risk factors becoming a factor as they were in the past. To protect against that, I would like to get a Blue Cross PPO now

      ***Click here to get proposals, benefits, subsidy calculation etc. http://www.quotit.net/eproIFP/webPages/infoEntry/InfoEntryZip.asp?license_no=0596610

      In the past we had HIPAA for those who lost COBRA. There was also MR. MIP – High Risk Pools.

      and just continue it until my Cobra expires.

      ***Losing COBRA gives you a Special Enrollment Period

      So therefore, I would have two health plans. My current Cobra group plan and an individual/family Blue Cross PPO plan.

      The questions I have are:

      Can I have two health plans (I’m not trying to commit fraud, I understand I cannot get paid more than the bill).
      Dual Coverage & Co-ordination Rules

      Let’s see if the question is asked on the paper application – I’m looking at doing this direct, no Covered CA no subsidies. For subsidies, the answer would definately be NO.

      Question G 2 asks about other coverage and if you plan to cancel it. So yes, you would have to disclose other coverage. I doubt they would write you. If it’s that important to you I could email them and ask. I could also check the ACA rules and see if the ACA law says you can buy coverage, even if you have other coverage.

      Do I need to tell Blue Cross?
      Yes, since they ask.

      Can I pick and choose who I want to use, if Blue Cross

      Please get a quote proposals, benefits, subsidy calculation. I don’t think Blue Cross has a PPO in your area. Try Blue Shield.

      has a doctor I like or pays more benefits for a particular procedure, can I only use them.

      These questions are quite complex and I think I’m going to have to charge a research fee for them. Under ACA, I practically have to work for free.

      See our page on Dual Coverage, see also the rules in the current evidence of coverage, if we can even get you an extra policy, that we do NOT recommend that you purchase!

      The same for Health Net PPO, use them if they are more beneficial for the procedure I have. – Please answer for Blue Cross, I have already got Health Net’s comment.
      Verbal comments are worthless!!!

      See the rules on dual coverage, basically the 2nd company pays up to 100% of what the first one didn’t. It may well be that there is NO co-ordination of benefits clause on two INDIVIDUAL policies. Thus, you could collect more than 100%, which is why I don’t think you will get a policy issued, if you plan to keep the first one.

      Note too, that I won’t give an answer, unless I can show it too you in writing or the law. I don’t want to have to pay the claim out of my pocket.

      My intent it to cancel my Health Net policy down the road

      I think you should keep it, till you really want to move and it expires. There is also Cal COBRA, which gives you another 18 months of coverage.
      but I have had it for 15 years and am leery just to let it go.
      Also, I go to doctors who do not take insurance. Can I go to doctors who do not take insurance and not let Blue Cross know I am having a procedure done?

      If you have a PPO, you could still turn in the claim. When a MD says they don’t take insurance, that just means they don’t agree to the negotiated rate, they still will cash the check.
      Usually the bills are below the deductible or I don’t want to wait for an approval – like an MRI)

      The question is beyond my pay grade.

      Reply
    4. Anonymous says:

      I worked at a company that paid fully for our health benefits. I quit, but they didn’t take me off their coverage for 6 months. They prior insurance company still paid for my Rx Prescriptions.

      One of the medications that was claimed with my old insurance needed a prior authorization in order to fulfill. Since my new insurance won’t cover it who is liable?

      Will the ACA clause regarding recession of coverage protect me from having to pay?

      Reply
    5. Anonymous says:

      How does Medi-Cal work with Employer Coverage?

      Reply
    6. Anonymous says:

      Can I get subsidies from Covered CA if I have another individual policy that I’m paying for.

      Reply
      • Steve Shorr says:

        Here are the Covered CA questions on other coverage. I don’t see a question about individual plans.

        Reply
        • Steve Shorr says:

          The Covered CA Paper application http://bit.ly/2pdp50f does ask about coverage one buys on their own

          Reply
          • Steve Shorr says:

            Grandfathered Plans count as MEC – Minimum Essential Coverage http://bit.ly/2CWFpo0

            BUT, the IRS Flow Chart on page 5 of Publication 974 http://bit.ly/2DwU4Yo says individual plans don’t count. So, I guess you are good. Please double check with competent tax and/or legal counsel.

      • Kevin Knauss says:

        IRS Instructions to Form 8962, “Coverage in the individual market outside the Marketplace. While coverage purchased in the individual market outside the Marketplace is minimum essential coverage, eligibility for this type of coverage does not prevent you from being eligible for the PTC for Marketplace coverage. Coverage purchased in the individual market outside the Marketplace does not qualify for the PTC.”

        While it looks like rules allow people to have both on on-exchange and off-exchange health plans, and receive the APTC, I don’t think people should expect the health plans to completely cover any health care claim twice.

        Reply
  7. Please expand on this paragraph:

    “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.”

    We have (Blue Shield HMO) (paid by employer); and (Medi-Cal via IEHP; no-shared-cost)….

    It would seem that most medi-cal providers do not bill correctly for this dual-coverage; and we end up paying for these copays; when we never paid them before… More coverage = less benefits…

    I went to the hospital for infection; the bill for nearly $3000; with approx 40% paid by insurance; so we received bill for approx 60%…

    The hospital said we must pay an additional $50 copay; before they can resubmit the bill to insurance…

    1) How should providers be billing in cases of medi-cal with additional insurance; specifically with copays, deductibles, etc…
    2) Should/can I seek reimbursement for these fees paid?

    • First off, I don’t get paid to help people with Medi Cal. It’s Covered CA’s branding to have a no wrong entry… but yet there is no compensation or support.

      2nd if you have other coverage like your employer plan, you can’t get a Medi Cal HMO. See response from Medi Cal Ombudsman below.

      Did you report your employer coverage to Medi Cal?

      Yes, I would try to get reimbursed… The problem is, do you really want to cancel IEHP and use fee for service?

      On the other hand, you have no choice but to report your employer health coverage and go on fee for service.

      • >>> [Other Health Coverage (OHC) and Medi-Cal]…
        My family has been on (Medi-Cal via IEHP) since at least 2012… My wife got employed at a local college in 2019; after the Covid-19 pandemic… We notified medi-cal; as required by law; of both added income and 2nd insurance (Blue Shield HMO, paid by employer)…

        Medi-cal enrolled us in “transitional coverage”, good for 3-6months…. Due to laws, my state coverage could not be terminated during the Covid pandemic, so lucky to maintain my coverage.

        So my questions; issues; was in regard to copay/deductible fees for (OHC)(Blue Shield HMO) services; should be paid by (Medi-Cal via IEHP)… The service providers have been making me pay these fees out-of-pocket… I tried to argue that fees not paid by (OHC); should be paid by (Medi-Cal via IEHP)… How should I proceed?!?

        • Your question is beyond our pay grade.

          Here’s our webpage on appeals & grievances

          Here’s the Medi Cal section

          Here’s our webpage on how to read a policy

          Heck, I have to look up what transitional coverage is. It’s for if you earn too much money to qualify for Medi Cal, they let you stay there for up to a year.

          I don’t see what that has to do with going on fee for service.

          Under FFS, Fee for Service 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.

          Check your IEHP Medi Cal Handbook for appeals procedures & dual coverage. Page 67 See page 65 about Medi Cal as payer of last resort.

          IEHP is an HMO and thus doesn’t pay, if you don’t use THEIR doctors.

          Sounds like Medi Cal made a boo boo not putting you into fee for service when you told them you have other coverage.

          On the other hand, they let you stay in Medi Cal, with too high an income.

          How about checking out Covered CA with subsidies. They are now especially high under ARPA. Nah, nevermind, you won’t get subsidies as you have employer coverage.

  8. 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]

  9. 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

  10. 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?

  11. 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!

  12. 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.

  13. 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.

  14. 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?

  15. 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

  16. 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.

  17. 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/

  18. 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?

  19. 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

  20. 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

  21. 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?

  22. 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.

  23. 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.

  24. 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.

  25. 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.

  26. 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.

  27. 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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