How to Use Medi-Cal as Secondary Insurance
Families who already have health insurance coverage for their child can still benefit from Medi-Cal (California’s Medicaid program), which may be used as secondary insurance to pay for certain expenses that primary health insurance doesn’t cover. Medi-Cal may also fund medical supplies, such as diapers and G-tube formula, and durable medical equipment (DME).
Whether your child qualifies for Medi-Cal based on the waiver program or based on your household income, here’s what you need to know about using fee-for-service or “straight” Medi-Cal as secondary coverage.
Applying for fee-for-service or straight Medi-Cal
There are several extra steps you must take to use fee-for-service or “straight” Medi-Cal as secondary coverage. After your child successfully enrolls in Medi-Cal, you will receive a packet in the mail that asks you to pick a county-managed health care plan. At this point, do not choose a county-managed plan.
Instead, contact Medi-Cal’s Health Care Options number at 800-430-4263 to confirm that they have your primary insurance plan on file. They refer to this as “other health coverage.” If they do not have the information, upload proof of your other health coverage at DHCS’s website and check back in with Health Care Options a few days later to make sure it shows in the system.
After this, your child should stay on straight Medi-Cal until January 1, 2023. In January 2023, most Medi-Cal recipients with private primary insurance will be transitioned from fee-for-service Medi-Cal to a managed care plan. Read more about this change here.
If you accidentally end up enrolled in a managed care plan when you want to stay on fee-for-service, it can be fixed in three steps:
- Upload proof of other health coverage, or update your coverage if it has changed.
- Call Health Care Options after a few days at (800) 430-4263 to make sure they have received and processed the documentation. Ask for an estimate of how long it will take to revise your child’s enrollment status.
- If the matter is urgent, or if enrollment status continues to show as “pending” with Health Care Options after three to five business days, contact the Managed Care Ombudsman at (888) 452-8609, and they should be able to expedite the change.
How to use Medi-Cal to cover copays and deductibles
Using Medi-Cal to cover services and supplies denied by private insurance
For services or supplies that aren’t completely covered by your primary insurance, you will need a written denial of coverage from your primary insurance as well as a prescription or order from your doctor showing that the service, medication, or supplies are medically necessary.
Example: A child requires a medically necessary piece of durable medical equipment that is excluded by the primary insurer. The parents should request a written denial. Once the written denial is received, parents can approach a DME company contracted with Medi-Cal and present the doctor’s prescription, a copy of the written denial, and their benefits ID card (BIC).
To get Medi-Cal to pay for consumables like incontinence supplies for children over the age of 3, you’ll follow the same process: obtain a written denial from your primary insurer and a prescription from your physician. In this clip, Leslie Lobel and Public Benefits Specialist Lisa Concoff Kronbeck explain what should be in a prescription from your doctor to get the supplies covered by Medi-Cal:
What to know about changes to fee-for-service Medi-Cal
By January 1, 2023, most families with private primary insurance will be transitioned from straight Medi-Cal to a managed care plan. DHCS has informed us that the managed care plan will be responsible for coordination of benefits, and families of children with complex medical needs will be contacted by an enhanced care coordinator from the managed care plan for further assistance. Be sure to read up on what to expect if your child is a Medi-Cal recipient with private health coverage.
Even after recipients transition to managed care by 2023, they will continue to access pharmacy benefits via fee-for-service Medi-Cal. This is a statewide policy change that affects all Medi-Cal recipients, and gives patients access to a more expansive network of pharmacies.
Because families will be required to choose a plan by January 1, 2023, now might be a good time to start researching whether or not your providers participate in a Medi-Cal managed care plan. You can use this information as a guide to help you decide which county plan to choose, especially if you anticipate using a particular provider frequently (for example, for ABA therapy or other recurring services).