Can you have medical and private insurance

Medi-Cal Managed Care HMO – Health Care Options 

#Pick your Plan

Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.

Learn more:

• Disability Rights.org  –
• What are Medi Cal Managed Care Plans?  What do I need to know?
• Medi-Cal Managed Care Health Plan Directory​
  • Medi-Cal Listing of HMO plans by county   *
  • Medi Cal HMO – Managed Care Providers by County
  • health care options.dhcs.ca.gov/tips-help-you-choose-medical-plan
  • health care options.dhcs.ca.gov/frequently-asked-questions-faqs
  • California’s County-Based Health Plans  2022  CHCF
• Poor Care Co-Ordination?  New contracting process   Deficient Oversight  CA Health Line *
• Disability Rights – Medi Cal provider HMO’s, what are they? What do I need to know about them?
• Medi-Cal Managed Care – Health Care Options
  • Get forms
• EOC’s, Forms & Income Charts from Insure Me Kevin.com
• Medi-Cal Managed Care Provider Search
• Sacramento? dhcs.ca.gov//mmcd health plan dir
• Exemption from enrolling in a Health Care Plan
  • health care options.dhcs.ca.gov
  • health care options.dhcs.ca.gov/Med Exemption WEB
    • You May Get A Medical Exemption If:
      • • You have a complex medical condition; AND
        • The care you get from your Regular Medi-Cal doctor for the complex medical condition
        cannot be changed, because your condition could get worse; AND
        • Your Regular Medi-Cal doctor is NOT part of a plan in your county. You may see
        more than one Regular Medi-Cal doctor. If you do, have the form filled out by the
        doctor who sees you most often. Ask your Regular Medi-Cal doctor if he or she is part
        of a Plan in your county. This should be done before you submit this form.
  • Provider Search – Statewide  Fee for Service
    • See our webpage on IMR Independent Medical Review

While you can have an employer or Indivudaul Plan and Medi Cal, there is However  a
#MANDATORY Medi Cal Managed Care – HMO health
Enrollment

One  must choose a  Managed Care – HMO health plan – provider within 30 days after enrollment in Medi-Cal otherwise the State will pick plan for you. Medi-Cal Website  Unless you have Other Health Coverage -OHC, then you must go Fee for Service.

When you have an HMO  managed health care, the State of California makes a deal  with health plans and pays a fixed amount each month per member enrolled in the plan – capitation.   The HMO health plan is then responsible for providing you  all your Medi-Cal services included under the EOC Evidence of Coverage.   HMO Plans are required under state and federal law to maintain an adequate Medi-Cal provider network to ensure that each member has a primary care physician and must report on quality and access measures.

• Medi Cal Managed Care Find a Provider
• See the email we rec’d May 17th from Medi Cal to clarify some of these issues
• chcf.org/primary-care-matters  * More readable summary * Health care systems with strong levels of primary care investment have better and more equitable health outcomes, lower care costs, and better care quality. We can build a healthier future for all Californians by focusing resources back to patients and their relationship with primary care providers.

#Clarification from Medi-Cal on
HMO Mandatory Enrollment and other coverage OHC

Hi Steve –

On May 8, you reached out to our Office of Communications, and requested answers to the following questions.  Please see DHCS’ responses*** below.

1. What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?

1. On this DHCS page, the public is told they must choose an HMO.  Nothing is said about if you have other coverage, it’s excluded. [not mentioned on the DHCS page?]

Medi-Cal managed care plans do not stop beneficiaries from enrolling in private health insurance plans.  If a Medi-Cal beneficiary is currently enrolled in a Medi-Cal managed care plan, and subsequently purchases private health insurance, they will not be disenrolled from the Medi-Cal managed care plan. 

The website above only applies to Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care plan, which is the large majority of the Medi-Cal population. 

1. On or about 10.26.2020 the Medi Cal Ombudsman emailed and said that if one had private insurance they could NOT enroll in a Medi Cal Managed Care Plan!

If a Medi-Cal beneficiary has active other health coverage upon Medi-Cal enrollment, they are currently not eligible for enrollment into a managed care plan. 

However, Medi-Cal beneficiaries with other health insurance will be eligible to enroll in a managed care plan after DHCS implements the California Advancing and Innovating Medi-Cal (CalAIM) initiative to transition share of cost beneficiaries to Medi-Cal managed care for non-duals (Medi-Cal coverage only) on January 1, 2022 and duals (Medicare and Medi-Cal coverage) in January 1, 2023.

1. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?

A Medi-Cal beneficiary who has other health insurance (OHC) is required to exhaust their OHC before Medi-Cal assumes payment for a service.  However, Medi-Cal providers are not allowed to deny a medically necessary service even if the provider has evidence that a beneficiary has OHC. In order for the provider to bill Medi-Cal for that service, the provider must first obtain a denial letter from the OHC entity.  (Other Health Coverage (OHC) Guidelines for Billing (other guide) (ca.gov) pg1)

1. When a member uses HMO services, how does the HMO collect & bill other coverage?

Assuming that you are referring to “HMO” as a Medi-Cal managed care plan, the State has direct data exchanges with commercial health insurance carriers to identify members with other health coverage. This data is shared with Medi-Cal Managed Care Plans to ensure effective coordination of benefits. If other health coverage information is present at time of billing, the Medi-Cal managed care plan will reject (not deny) the claim and provide the other health coverage information to the provider for billing. If other health coverage information is obtained after a Medi-Cal managed care plan has paid for the claim, the plan will initiate post-payment recovery.

1. When a member uses say his Employer’s HMO or PPO how does the  collect copays & deductibles  from Medi Cal HMO and/or fee for service?

Medi-Cal managed care plans and Medi-Cal fee-for-service do not pay for a Medi-Cal beneficiary’s copays or deductibles for their employer’s HMO/PPO plan. 

The DHCS Health Insurance Premium Payment program does offer an option for a narrow population of newly enrolled Medi-Cal beneficiaries to receive reimbursement for OHC co-pays and deductibles for a limited time, subject to eligibility requirements.  Please see dhcs.ca.gov for additional information.   

1. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
   is CA using?

1. How is this being enforced & implemented?

                 CA currently uses the two out of four approaches:

·  Enrollees with any other insurance coverage are excluded from enrollment in managed care (note that this will change after Cal AIM implementation)

· Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments

o This approach is used when a Medi-Cal beneficiary is first enrolled in a Medi-Cal managed care plan and subsequently obtains other health coverage. TPL responsibilities are then delegated to the Medi-Cal managed care plan for the first 12 months after the date of payment for a service.

If you have any additional questions on other health coverage and Medi-Cal, please let me know.

Thank you!

Lindsey Wilson, Chief

Coordination of Benefits and Administration

Third Party Liability and Recovery Division 

***Please note that a few things in the letter were changed, so that it would look better when posted on the web.

Contrast…

What is Medi Cal Fee for Service?

FFS Fee for Service

Under FFS Fee for Service, the California state pays enrolled Medi-Cal providers directly for covered services provided to Medi-Cal enrollees. It is the enrollee’s  responsibility to find a physician who accepts Medi-Cal. CHFS.org*

How much does Medi Cal pay?

Medi-Cal Fee for Service will pay the maximum that they are allowed to! 

Here’s information what Full Scope Medi Cal  * or see what the HMO’s Evidence of Coverage say, and Denti -Cal Cover. Of course Medi Cal  will deduct the payment amount, from your other health plan, 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 Medi-Cal 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.

For Medi Cal HMO’s check out each one’s summary of benefits and EOC’s Explanation of Benefits.

How do I find a provider that accepts Medi Cal?

Sorry there isn’t a  Fee For Service provider directory.  Try calling  Medi Cal @  1-800-541-5555. You may need to call providers to see if they accept FFS Medi-cal. Email from Ombudsman 1.26.2021 *

See the email we rec’d May 17th from Medi Cal to clarify some of these issues

 (HIPP) Health Insurance Premium Payment Program/Cost Avoidance

The Health Insurance Premium Payment (HIPP) program is a voluntary program for qualified beneficiaries with full scope Medi-Cal coverage. HIPP approved Medi-Cal eligible beneficiaries shall receive services that are unavailable from third party coverage and offered by Medi-Cal.  Learn More 

Can you have other insurance with Medi Cal?

Is it obligatory to have health insurance in the Netherlands?