Medi-Cal - What it means to you 39 pages

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.

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

Which Insurance Plan pays #first
Medi-Cal or OHC Other Health Coverage?

Under federal law, your private health insurance must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including your other plans co-payments, co-insurance and deductibles.   See below about if you have a Medi Cal HMO.   Also, you may have a problem if you went to a provider that isn’t a Medi Cal doctor.   You may not quote this page.  It’s a summary of what we have footnoted and linked to from official documents & law.  Cite only those.

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.

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

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.

BIC Benefits Identification Card

Sample BIC Card

How to replace lost or stolen card?  

 

#My Medi-Cal
How to get the Health Care You Need
24 pages

Smart Phones - try turning sideways to view pdf better
My medi cal explanation of medi cal

 

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Western Poverty Law - Insurance for Low Income

Advocate Guide to Medi Cal 

advocate guide to Medi Cal

Nolo Social Security, Medicare, Medi Cal & Government Pensions

nolo social security government pensions

Our Webpage on

COVID 19

symptoms of corona virus

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

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

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

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

Hi Steve –
 
On May 8, you reached out to our Office of Communications, and requested answers to the following questions.  Please see DHCS’ responses*** below.
 
  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. [not mentioned on the DHCS page?]
 
Medi-Cal managed care plans do not stop beneficiaries from enrolling in private health insurance plans.  If a Medi-Cal beneficiary is currently enrolled in a Medi-Cal managed care plan, and subsequently purchases private health insurance, they will not be disenrolled from the Medi-Cal managed care plan. 
 
The website above only applies to Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care plan, which is the large majority of the Medi-Cal population. 

 

 

 
 
  1. On or about 10.26.2020 the Medi Cal Ombudsman emailed and said that if one had private insurance they could NOT enroll in a Medi Cal Managed Care Plan!
 
If a Medi-Cal beneficiary has active other health coverage upon Medi-Cal enrollment, they are currently not eligible for enrollment into a managed care plan. 

 

 

 
However, Medi-Cal beneficiaries with other health insurance will be eligible to enroll in a managed care plan after DHCS implements the California Advancing and Innovating Medi-Cal (CalAIM) initiative to transition share of cost beneficiaries to Medi-Cal managed care for non-duals (Medi-Cal coverage only) on January 1, 2022 and duals (Medicare and Medi-Cal coverage) in January 1, 2023.
 
  1. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?
 
A Medi-Cal beneficiary who has other health insurance (OHC) is required to exhaust their OHC before Medi-Cal assumes payment for a service.  However, Medi-Cal providers are not allowed to deny a medically necessary service even if the provider has evidence that a beneficiary has OHC. In order for the provider to bill Medi-Cal for that service, the provider must first obtain a denial letter from the OHC entity.  (Other Health Coverage (OHC) Guidelines for Billing (other guide) (ca.gov) pg1)
 
  1. When a member uses HMO services, how does the HMO collect & bill other coverage?
 
Assuming that you are referring to “HMO” as a Medi-Cal managed care plan, the State has direct data exchanges with commercial health insurance carriers to identify members with other health coverage. This data is shared with Medi-Cal Managed Care Plans to ensure effective coordination of benefits. If other health coverage information is present at time of billing, the Medi-Cal managed care plan will reject (not deny) the claim and provide the other health coverage information to the provider for billing. If other health coverage information is obtained after a Medi-Cal managed care plan has paid for the claim, the plan will initiate post-payment recovery.
 
  1. When a member uses say his Employer’s HMO or PPO how does the  collect copays & deductibles  from Medi Cal HMO and/or fee for service?
 
Medi-Cal managed care plans and Medi-Cal fee-for-service do not pay for a Medi-Cal beneficiary’s copays or deductibles for their employer’s HMO/PPO plan. 
 
The DHCS Health Insurance Premium Payment program does offer an option for a narrow population of newly enrolled Medi-Cal beneficiaries to receive reimbursement for OHC co-pays and deductibles for a limited time, subject to eligibility requirements.  Please see dhcs.ca.gov for additional information.   

 

 

 

 
  1. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
    is CA using?
  1. How is this being enforced & implemented?
 
                 CA currently uses the two out of four approaches:

 

 

 

 
·  Enrollees with any other insurance coverage are excluded from enrollment in managed care (note that this will change after Cal AIM implementation)
· Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments
o This approach is used when a Medi-Cal beneficiary is first enrolled in a Medi-Cal managed care plan and subsequently obtains other health coverage. TPL responsibilities are then delegated to the Medi-Cal managed care plan for the first 12 months after the date of payment for a service.
 
If you have any additional questions on other health coverage and Medi-Cal, please let me know.
 
 
Thank you!
 
Lindsey Wilson, Chief
Coordination of Benefits and Administration
Third Party Liability and Recovery Division 
 
***Please note that a few things in the letter were changed, so that it would look better when posted on the web.
 
 
Contrast…
 
You cannot choose a medical HMO Managed Care plan if:

 

 

 

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

You must take Fee for Service.

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

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

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

What is Medi Cal Fee for Service?

FFS Fee for Service

Under FFS Fee for Service, the California state pays enrolled Medi-Cal providers directly for covered services provided to Medi-Cal enrollees. It is the enrollee’s  responsibility to find a physician who accepts Medi-Cal. CHFS.org *

How much does Medi Cal pay?

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

Here’s 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.

 

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 *

 

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

 

 

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Life Insurance Buyers Guide

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How much  life insurance you really need?

Video Insurance Unnecessary Cost?

Medi Cal Contact Information

#Email  Addresses & Phone #'s: 

Ombudsman

  • Ombudsman Webpage
    • Phone: 1-888-452-8609
    • Email:   [email protected] 
      • The Office of Ombudsman cannot approve/terminate/reinstate Medi-Cal eligibility; alter aid codes, change/update addresses, change/update name or initiate inter-county transfers.

Complex Questions Assistance

Medi-Cal for All Children program 

SB 75 Eligibility and [email protected]

Medi Cal - #County Office Lookup

See our Main Webpage on Medi Cal contact information

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:

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.

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 

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

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

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

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?

Employer Dental & Individual Dental?  

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 Steve's Video

Video understanding medicare advantage mapd

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

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

Medicare #DualCoverage
# 02179
 
 

Medicare Dual Coverage Pamphlet

Our Webpage on Medicare & Dual Coverage 

Coordination of benefits -
two or more insurance plans
VIDEO 

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

A Primer on Dual-Eligible Californians:  How People Enrolled in Both Medicare and Medi-Cal Receive Their Care Chcf.org

cms.gov/MMP Marketing Information and Resources

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

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

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

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

  1. I am debating on whether to sign up for UCSHIP at Berkeley or to opt-out.

    I am also on my parents’ Medi-Cal with Kaiser through LA Care and HealthNet Dental.

    1. Can I have both insurances at the same time or will I get dropped from Medi-Cal?

    I know when I am on campus I should go to the University Health Services facility for care.

    However I’m a little confused about where I should go when I am back home.

    2. Can I still go to the usual Kaiser facility and HealthNet Dental Provider?

    I don’t want my parents to to get a huge bill when I get treatment at home.

    How would the insurance work?

    Please help. Thank-you in advance!

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