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, private health insurance belonging to a Medi-Cal beneficiary must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including OHC co-payments, OHC co-insurance and OHC deductibles.

Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC payment amount, if any. Medi-Cal will not pay the balance 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. 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. The correct information then needs to be reported to DHCS.  Click here to correct this information,

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.

Note: Beginning January 1, 2006, if you are a recipient of both Medicare and Medi-Cal, 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). For  information on Medicare Part D (drug coverage), please contact 1-800-MEDICARE (1-800-633-4227).  Copied from  “Medi-Cal What it Means to you”  Section 12 

 

Medi-Cal Eligibility if you have
Other Health Coverage

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.  Medi-Cal beneficiaries who are enrolled in managed care are also subject to this requirement due to current contracting provisions, 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. As such, California requires that applicants and beneficiaries 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.57

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 or with maternity-only deductibles or co-payments greater than $500. For more information on MCAP, see Chapter 2, Section C.3.b. Similarly, the 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. For more information on BCCTP, see Chapter 3, Section E.1.  Copied from Western Poverty Guide – Page 40 on dual coverage

Footnotes

53. Non-immigrants with valid visas can claim state residency for Medi-Cal purposes, but should first be advised to seek legal advice because there may be immigration consequences depending on the type of visa. Individuals who are lawfully present yet
denied Medi-Cal due to immigration status may enroll in Covered California even if below 100% FPL. See Chapter 4, Section C.2.a.

54. 42 U.S.C. § 1396a(a)(25); Welf. & Inst. Code § 10020; 22 CCR § 50763(a). Note that the California regulations specify that Medi-Cal applicants and beneficiaries shall “apply for, and/or retain any available health care coverage when no cost is involved” but
DHCS regularly requires beneficiaries to use other health coverage with co-pays and deductibles. See also Welf. & Inst. Code § 14023.7 (regarding provider obligations to bill private health insurance); Welf. & Inst. Code § 14023 (regarding penalties for failure to disclose entitlement to other health coverage.).

55. See 22 CCR § 50761 allowing this arrangement via the contract.

56. 42 U.S.C. § 1396a(a)(25); 42 C.F.R. §§ 433.137-433.140.

57. Welf. & Inst. Code § 14008.6. However the regulations do provide good cause exceptions where doing so would cause harm to the child, parent or other caretaker relative. 22 CCR § 50771.5(b).

Links & Resources

Medicare Publication # 02179. on dual coverage 

See also our page on DUAL COVERAGE. for all types of different combinations of plans.

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. Friendly Agent’s Blog on how to have different plans for different members of the family.    

Instant Quotes and enroll in Health Insurance

   

 

Insurance Agents pretty much can't help you with Medi Cal

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   

Try Covered CA's Facebook Page https://www.facebook.com/CoveredCA/

 

Direct Phone # for Medi Cal
866.613.3777
Direct Phone # 866.613.3777

37 comments on “Dual Coverage? Medi-Cal & Individual Private or Employer Plans?

  1. 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.

  2. I have primary health insurance through employment, but it is a high deductible and out of pocket plan.

    Will Medi-cal pay my primary health insurance out of pocket?

  3. 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/

  4. 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?

  5. 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

  6. When I call Medi-Cal to give them the proof of private insurance they tell me I have to call my local SSI office to give them my info and those good folks told me I have to call Medi-Cal.

    Who really can straighten this typical government back and forth?

  7. 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

  8. 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?

  9. Really Appreciate this update, can you make it so I receive an update sent in an email whenever there is a new article?

    • Our Medi-Cal website is Pro Bono, so we are not doing a whole lot of updates… In the lower right hand corner of the page if your on a desktop computer or just scroll down if your using a smartphone, just enter your email and you can subscribe. One problem is, that we use pages and not posts. Posts are what gets sent out…

  10. 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.

  11. 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.

  12. 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.

  13. 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

      Here is Health Net’s Evidence of Coverage for Medi-Cal other coverage shows on page 55. 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.

  14. 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?

Leave a Reply

Your email address will not be published.

wp-puzzle.com logo