Dual Coverage: Medi-Cal And Private Insurance

In California, residents can benefit from having both private insurance and Medi-Cal, California's Medicaid program. Medi-Cal provides low-cost or free health insurance to eligible residents with limited incomes. It can be used as secondary insurance to cover expenses that primary insurance doesn't, including medical supplies and equipment. For those with multiple insurance plans, Medi-Cal is the payer of last resort, meaning that it covers remaining costs or copayments after the primary insurance pays its share, as long as the provider contracts with the specific form of Medi-Cal that the recipient receives.

Medi-Cal can be used as secondary insurance to pay for expenses that primary health insurance doesn't cover

Medi-Cal, California's Medicaid program, can be used as secondary insurance to pay for expenses that primary health insurance doesn't cover. This is particularly useful for families with children who already have health insurance coverage but can benefit from Medi-Cal. It is important to note that if a child has multiple insurance plans, Medi-Cal is always the payer of last resort, meaning it is the last provider to be billed. The child's private insurance is primarily responsible for their healthcare coverage.

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. This will involve presenting both your primary insurance card and your Medi-Cal card to the provider and requesting that they bill Medi-Cal after the private insurance pays its portion. It is essential to ensure that the provider contracts with both the private insurance and the specific form of Medi-Cal that the child receives.

Medi-Cal can help cover expenses such as medical supplies, including diapers and G-tube formula, and durable medical equipment (DME). It is also worth noting that "balance billing" is prohibited for Medi-Cal-covered treatments. This means that providers cannot charge patients for the difference between the Medi-Cal reimbursement rate and the customary charge for a service. However, patients are still responsible for any services or procedures not covered by Medi-Cal.

To utilise Medi-Cal effectively, it is recommended to first ensure that your physician, facility, or service accepts your primary insurance. Subsequently, you can inquire about their contract status with your chosen Medi-Cal managed care plan. This way, they can bill your primary insurance first and then bill the remaining amount to Medi-Cal. By following these steps, you may be able to have certain services, such as occupational, physical, speech, or ABA therapy, entirely covered.

It can also fund medical supplies and durable medical equipment

In the United States, those with both private insurance and Medi-Cal (California's Medicaid program) can benefit from having the latter as secondary insurance to cover certain expenses that primary health insurance doesn't. This includes medical supplies and durable medical equipment (DME).

DME is a device or tool that is medically necessary for a patient. It must be vital to your daily life, like an oxygen tank or blood sugar tests for diabetics, and not just for your comfort. DME can be used temporarily, for example, if you need crutches while recovering from surgery. It is typically used at home and includes items such as blood sugar monitors, test strips, and wheelchairs.

Medicare Part B covers medically necessary DME if prescribed for home use by an enrolled doctor or healthcare provider. You may need to rent or buy the equipment, and you will pay 20% of the Medicare-approved amount after meeting the Part B deductible.

Medicaid programs vary by state, but generally, they will cover medical equipment that is medically necessary and cost-effective, meeting the state's definition of DME. Many state Medicaid programs cover 100% of the cost of any home medical equipment required.

Private health insurance plans are not mandated to cover DME, but many do. If your plan includes DME coverage, you will typically need a prescription from your doctor. Your plan will detail whether you can rent or buy DME and how the costs are covered.

It is important to note that vehicles, car customizations, and home improvements like ramps and grab bars are generally excluded from DME coverage, unless deemed medically necessary by the insurance company.

Available Medi-Cal plans vary depending on your county

In California, the availability of Medi-Cal plans depends on the county in which you reside. County human services departments are responsible for administering the Medi-Cal program at the local level.

Most counties offer commercial plans such as Anthem Blue Cross, Kaiser Permanente, Health Net, and Molina. However, some counties offer public plans administered by the community. If a county only offers one plan, all Medi-Cal members in that county will be enrolled in that plan. Almost all Medi-Cal plans are "managed care plans", which means they function similarly to an HMO.

In Los Angeles County, the available plans include HealthNet or LA Care and its contracted programs, including Anthem Blue Cross and Blue Shield of California Promise Health Plan. Kaiser may be available on a limited basis, generally only to current and recent Kaiser patients (with Kaiser coverage in the past 12 months), as well as patients who have a family member with Kaiser, current and former foster youth, and individuals with both Medicare and Medi-Cal.

To find out which plans are available in your county, you can refer to the Medi-Cal Managed Care Health Plan Directory. This directory provides a comprehensive list of Medi-Cal plans offered in each county. Additionally, the California Department of Health Care Services (DHCS) offers online resources to help you choose the right managed care plan. You can compare multiple health care or dental plans, find information on standard benefits, pharmacies, urgent care centres, and more.

If a child has multiple insurance plans, Medi-Cal is the payer of last resort

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. This will involve presenting your primary insurance card along with your Medi-Cal card to a provider and asking them to bill Medi-Cal after the private insurance pays its portion.

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

To ensure smooth coordination of benefits, it is recommended to first confirm that your physician, facility, or service accepts your primary insurance. Subsequently, you can inquire about their contract status with your Medi-Cal managed care plan. If they are contracted with both, they can bill your primary insurance first and then bill the remaining amount to Medi-Cal.

By following these steps, you may be able to maximize the utilization of your insurance coverage and minimize out-of-pocket expenses for services like occupational, physical, speech, or ABA therapy.

Medi-Cal can be used to cover copays and deductibles

If you have multiple insurance plans, you may be able to use Medi-Cal to cover copays and deductibles. However, it's important to note that Medi-Cal is always the payer of last resort, meaning that it will only cover costs after your primary insurance and any other secondary private insurance has paid its share.

To use Medi-Cal to cover copays and deductibles, you will need to present both your primary insurance card and your Medi-Cal card to your provider and ask them to bill Medi-Cal for the amount not covered by your primary insurance. It is important to ensure that your provider is contracted with the specific form of Medi-Cal that you receive. Additionally, "balance billing" is prohibited for Medi-Cal-covered treatments, meaning that your provider cannot charge you for the difference between the Medi-Cal reimbursement rate and the customary charge for a service.

If your provider does not accept Medi-Cal, you may still be able to get copayment assistance through the Regional Center if you qualify as a Regional Center client.

By using Medi-Cal as secondary insurance, you may be able to get certain services, such as occupational, physical, speech, or ABA therapy, entirely covered by first using your primary insurance and then using Medi-Cal to pay for the remaining costs.

Frequently asked questions