Making the Most of Medi-Cal
What are the benefits of Medi-Cal eligibility?
What is coordination of benefits (COB)?
Types of Medi-Cal
County-managed Medi-Cal plans
Children without a private primary insurer must enroll in a Medi-Cal managed care plan such as 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. Available plans vary depending on your county. If you do not select a plan, you will be assigned one.
Managed care plans can also be used as secondary insurance if families enroll in the same Medi-Cal HMO as their primary insurance (if it is available in their county). In these cases, as with fee-for-service, Medi-Cal typically covers what the primary insurance doesn’t.
There are some great online resources to help you choose the right managed care plan as your child’s sole insurance coverage. You can use the California Department of Health Care Services (DHCS) to:
Compare up to three health care or dental plans.
Find information on standard benefits, pharmacies, urgent care centers, and more.
Search for a specific provider or hospital to see if they accept a Medi-Cal managed care plan.
Get contact information for each provider.
Fee-for-service (“straight”) Medi-Cal
What to do when Medi-Cal denies a claim
If Medi-Cal denies coverage for something your child needs, you are entitled to an appeal. An appeal is used when your care plan has taken an Adverse Benefit Determination (ABD), or an action “that affects your care, such as delay, modification, denial, or reduction of services, denial or only partial payment for a service, or the determination that the requested service was not a covered benefit.”
The appeal process changes depending on whether you are enrolled in a managed care plan or straight Medi-Cal:
Those with straight Medi-Cal can contact their county office to file a formal complaint and request a Medi-Cal Fair Hearing.
If you’re on a managed care plan, contact your plan’s customer service number. If this does not resolve the problem, you can file an appeal with your care plan. For assistance with this process, you can contact the Medi-Cal Managed Care and Mental Health Office of the Ombudsman.
If a managed care plan does not contract with any providers for a service that is medically necessary and is otherwise covered by Medi-Cal, recipients may request a TAR via fee-for-service Medi-Cal. For example, if your doctor has ordered home LVN care for your child but your managed care plan does not contract with any home health agencies, the service may be accessed through fee-for-service Medi-Cal instead. The managed care plan remains the starting point for initiating this process as they will need to provide documentation that they don't contract for the service.