If you have Medi-Cal and other insurance,
how much does each one pay?
Which pays first?
Private Health Insurance, Other Health Coverage (OHC) and Medi-Cal
You can have Medi-Cal even though you have Other Health Coverage (OHC) through individual or group private health (or dental) insurance coverage. If you are a Medi-Cal beneficiary and have individual or group private health (or dental) insurance coverage, you are required by federal and state law to report it. You can report it directly to Department of Health Care Services (DHCS) by visiting their webpage on that.
You can also report it to your county eligibility worker, your health care provider, and/or to the Local Child Support Agency (LCSA), when there is an absent parent who may be responsible for your child(ren)’s medical care, or in establishing paternity of a child born out of wedlock. If you fail to report any private health insurance coverage that you have, you are committing a misdemeanor.
Under federal law, your private health insurance must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including your other plans co-payments, co-insurance and deductibles. See below about if you have a Medi Cal HMO. Also, you may have a problem if you went to a provider that isn’t a Medi Cal doctor. You may not quote this page. It’s a summary of what we have footnoted and linked to from official documents & law. Cite only those.
Medi-Cal will pay the maximum that they are allowed to!
Of course they will deduct the OHC payment amount, if any. Medi-Cal will not pay higher charges of a provider’s bill when the provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as payment in full. See our webpage on negotiated rates. The MediCal provider must submit an Explanation of Benefits or denial letter from the OHC along with the Medi-Cal claim. If Medi-Cal later discovers OHC, Medi-Cal will bill the OHC for the Medi-Cal services.
If you have a Medi-Cal share of cost you must pay it before Medi-Cal will pay for your service. If your other health insurance is a Prepaid Health Plan (PHP) or a Health Maintenance Organization (HMO), you must use the plan facilities for regular medical care (non-emergency services).
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 correct your information ONLINE!
If you are having a claims payment problem with a provider, you may call the Beneficiary and HIPAA Privacy Help Desk at (916) 636-1980.
If you have both Medicare and Medi-Cal, aka Medi Medi Medicare (not Medi-Cal) will pay for most prescription drugs for Medi-Cal beneficiaries who are eligible for Medicare Part A (hospital) or Part B (outpatient). Here’s our webpage on Medicare Part D (drug coverage) “Medi-Cal What it Means to you” Section 12
Can you get Medi Cal
If you have other insurance?
If you have other health coverage you may be eligible for Medi-Cal, but you must use your other health coverage, first. If you are in a HMO – Managed Care Providers coordination may be difficult.
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.
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
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.
Excerpt of email from DHCA
Thank you for contacting the Department of Health Care Services (DHCS).
We are prohibited by law from sharing Protected Health Information (PHI), and Personal Confidential Information (PCI).
Please refer the consumer to the Medi-Cal Now In-Box at [email protected] and we will be happy to assist them with any Medi-Cal issues they may have.
Protected Health Information (PHI) is individually identifiable health information that describes the past, present, or future physical or mental health or the condition of an individual. PHI includes information about the health care services an individual has received or will receive and information about payment for health care services provided in the past, present, or future. Personal confidential information (PCI) is information that is not public which identifies or describes an individual including names, home addresses, home telephone numbers, Social Security Numbers, medical or employment histories, personnel records, licensing records or workers’ compensation. Thank you for allowing DHCS to serve you. Email dated 6.5.2017 10:43 AM
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