Understanding Primary Insurance: Medi-Cal Vs Private Insurance

Medi-Cal is California's Medicaid program, which offers free or low-cost health insurance to eligible residents with limited incomes. It can be used as secondary insurance to pay for certain expenses that primary health insurance doesn't cover. For instance, if a child has multiple insurance plans, Medi-Cal is the payer of last resort, meaning the child's private insurance bears primary responsibility for healthcare coverage. However, if an individual has private health insurance, they can still qualify for Medi-Cal as an additional coverage option.

Medi-Cal as secondary insurance

Medi-Cal is California's Medicaid program, which provides health coverage to people with low incomes and assets who meet certain eligibility requirements. Even if you have private health insurance, you can still benefit from Medi-Cal as secondary insurance to pay for certain expenses that your primary health insurance doesn't cover. This includes medical supplies, such as diapers and G-tube formula, and durable medical equipment (DME).

If you have a child with multiple insurance plans, including Medi-Cal, the private insurance is billed first, and any remaining costs or copayments can be billed to Medi-Cal up to the Medi-Cal reimbursable rate. This means that Medi-Cal acts as the secondary payer and will cover any additional services that it includes but the primary insurance does not.

To use Medi-Cal as secondary insurance, present your primary insurance card along with your Medi-Cal card to your provider and ask them to bill Medi-Cal after your private insurance pays its portion. It is important to ensure that your physician, facility, or service accepts your primary insurance and that they contract with your Medi-Cal managed care plan.

Additionally, some medical services provided by Medi-Cal require a treatment authorization request (TAR) beforehand. Your provider can use a TAR form to request authorization and receive payment for services like physical therapy, DME, and speech therapy.

In the case of services or supplies that aren't completely covered by your primary insurance, you will need a written denial of coverage from your primary insurer, along with a prescription or order from your doctor indicating that the service, medication, or supplies are medically necessary.

It is important to note that "balance billing" is prohibited for Medi-Cal-covered treatments. This means that a provider cannot charge you for the difference between the Medi-Cal reimbursement rate and the customary charge for a service. However, you will still be responsible for any services and procedures that are not covered by Medi-Cal.

Medi-Cal for families with children

Medi-Cal is California's Medicaid program, which provides comprehensive health coverage for children and families. Depending on income and family size, families may be eligible for free or low-cost Medi-Cal. To qualify for Medi-Cal, a family's income must be within the limits for the appropriate family size, based on the Federal Poverty Levels (FPL). If a family's income is above the FPL limits, they can request to be evaluated for other Medi-Cal programs, which may include coverage with a Share of Cost.

To be eligible for Medi-Cal, families must reside in California and provide information about their income, as well as verification of other necessary information if requested. The parent or caretaker relative must have at least one child under the age of 19 (or under 21 if a full-time student).

Medi-Cal offers a range of services for children, including:

• Free services, such as well-baby visits and checkups
• Ambulance and emergency room services
• Doctor visits for sickness, injuries, or other concerns
• Teeth cleanings, fillings, eye exams, and glasses
• Prescription coverage (low-cost or free)
• Mental health and substance use disorder counseling and treatment

In some cases, parents may qualify for Covered California, while their children are eligible for Medi-Cal or another program. It is important to note that parents cannot decline Medi-Cal enrollment for their children and add them to their Covered California plan. If parents decline Medi-Cal enrollment, their children can only be enrolled in a separate, full-cost (unsubsidized) plan through Covered California.

Additionally, families who already have health insurance coverage for their children can still benefit from Medi-Cal as secondary insurance to pay for certain expenses not covered by the primary insurance. Medi-Cal may also fund medical supplies, such as diapers and durable medical equipment (DME).

Medi-Cal for those with private insurance

Medi-Cal is California's Medicaid health care program. It helps low-income families get health coverage at little to no cost. It is possible to have both private insurance and Medi-Cal, with the former acting as the primary insurance and the latter as secondary insurance.

If you have private health insurance, you can still qualify for Medi-Cal. Members who already have insurance can add Medi-Cal coverage to their existing plan. Your provider will first bill your private insurance, and then Medi-Cal will pay for any additional services it covers.

If a child has multiple insurance plans, Medi-Cal is always the payer of last resort. The child's private insurance bears primary responsibility for health care coverage. Any other secondary private insurance must be billed before Medi-Cal will cover the service. The provider must contract with both the private insurance and the Medi-Cal managed care plan.

If there are remaining costs or copayments after the primary insurance pays its share, Medi-Cal can be billed for the amount not covered by the primary insurance, up to the Medi-Cal reimbursable rate, as long as the provider is contracted with the specific form of Medi-Cal that the child receives.

To use Medi-Cal, you will need to select a Medi-Cal managed care plan. Available plans vary depending on your county. If you do not select a plan, you will be assigned to one.

Medi-Cal eligibility

In California, Medi-Cal is the name for the Federal Medicaid Program. It provides comprehensive health coverage for children, adults, and families with limited income. Depending on income and family size, individuals may be eligible for free or low-cost Medi-Cal.

Undocumented adults are not eligible for Medi-Cal, but undocumented children can qualify. Adults who receive income need to provide information about their unemployment benefits or employment. The required documents can vary and could include proof of unemployment benefits or pay stubs.

Pregnant women may be eligible for free or low-cost health care coverage during their pregnancy. Pregnant women can also apply for the Medi-Cal Access Program (MCAP), which offers low-cost coverage based on income.

Former foster youth are eligible for free Medi-Cal until the age of 26 if they were in foster care on their 18th birthday.

Seniors and people with disabilities are also eligible for health care assistance.

Medi-Cal vs Covered California

Medi-Cal and Covered California are both health insurance programmes for Californian residents. However, there are some key differences between the two.

Medi-Cal

Medi-Cal is California's Medicaid programme, offering low-cost or free health insurance to eligible residents with limited incomes. It is designed for low-income or no-income residents, including children, pregnant women, and people with disabilities. Undocumented children can qualify for Medi-Cal, but undocumented adults cannot. Depending on your income and family size, you may also qualify for government discounts through the Affordable Care Act.

Covered California

Covered California is the state's health insurance marketplace, where residents can shop for health plans and access financial help if they qualify. It is intended for those who earn too much to qualify for Medicaid but still need financial assistance.

Applying for Medi-Cal and Covered California

You can apply for both programmes at the same time using a single application. You can apply online, in person, or over the phone. The application process requires information about you and your family members, including Social Security numbers, immigration documents, income and employment information, and federal tax information.

Using Medi-Cal and Private Insurance Together

If you have private health insurance, you can still qualify for and use Medi-Cal as secondary insurance to pay for certain expenses that your primary insurance doesn't cover. In this case, your private insurance will be billed first, and then Medi-Cal will pay for any additional services it covers. It's important to note that Medi-Cal supports but does not override your primary insurance, so you should ensure that your physician or service provider accepts your primary insurance before seeking treatment.

Both Medi-Cal and Covered California offer important benefits to Californian residents, with Medi-Cal catering to those with limited incomes and Covered California providing a marketplace for those who need financial assistance to obtain health insurance.

Frequently asked questions