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). You can see a list of commonly covered services in our Medi-Cal glossary.
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 Medi-Cal as secondary coverage.
Most new enrollees are required to select a Medi-Cal managed care plan regardless of whether or not they have private primary insurance.. In Los Angeles County, these 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.
Available plans vary depending on your county. If you do not select a plan, you will be assigned to one.
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:
You can also see our article on how to prepare and choose a plan.
Note: Very few recipients will remain on fee-for-service, aka “straight,” Medi-Cal. Such limited exceptions include recipients with a Share of Cost, recipients on a limited-scope Medi-Cal plan, people who receive medical exemptions (not usually available for those with private health coverage), and some children in the state’s foster child program, depending on their county.
If a child has multiple insurance plans, Medi-Cal is always the payer of last resort — in other words, the last provider to be billed. The child’s private insurance bears the 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. In practice, this will look like 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.
Note that “balance billing” — the practice of charging a patient for the difference between the Medi-Cal reimbursement rate and the customary charge for a service — is prohibited for Medi-Cal-covered treatments. For example, if a provider charges a certain rate for a therapy, and the private insurance pays its portion and then Medi-Cal pays the remainder of the bill up to the contracted Medi-Cal rate, the provider cannot bill the patient for any amount left over after Medi-Cal pays its share. However, the patient will still be responsible for any services and procedures that are not covered by Medi-Cal.
Because Medi-Cal supports your primary insurance (including vision and dental insurance) and does not override it, you should first make sure your physician, facility, or service accepts your primary insurance. Then, you can ask if they contract with your Medi-Cal managed care plan. If they do, they can bill your primary insurance before billing the amount not covered to Medi-Cal.
By following these instructions, you may be able to get a service like occupational, physical, speech, or ABA therapy entirely covered by first using your primary insurance and then using Medi-Cal to pay for the rest. As always, there are some exceptions, as Director of Health Plan Advocacy Leslie Lobel explains in this clip.
Some medical services provided by Medi-Cal require a treatment authorization request (TAR) beforehand. Ask your provider whether a service will need a TAR and how long the authorization process could take. (If you have a TAR number from your provider, you can find the status on the state website). This can save you time and frustration in the future.
Your provider can use a TAR form to request authorization and receive payment for services like physical therapy, DME, and speech therapy. If your service provider accepts your Medi-Cal plan, they should already know when and how to submit a TAR. Although a provider will typically request a TAR before providing the service, there are some exceptions, such as for acute hospital stays. In these cases, a TAR will need to be submitted and approved retroactively.
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 the Medi-Cal managed care plan and present the doctor’s prescription, a copy of the written denial, and their benefits ID card (BIC).
If your insurance plan denies a service because it is not medically necessary, you should review your policy’s definition of medical necessity because it may be more narrow than the state’s pediatric standard. For children under age 21, Medi-Cal defines a service or treatment as medically necessary when it is needed “to correct or ameliorate health defects, physical and mental illnesses, and conditions discovered by the screening services.”
It is possible for a service or treatment to be denied for medical necessity by a private insurance company but to meet the more expansive pediatric definition under Medi-Cal. Private duty nursing is an example of a service that is frequently viewed as medically unnecessary by private plans due to their criteria for home health services, but it may be medically necessary per Medi-Cal standards.
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:
