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
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.
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