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.

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.

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.

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, if 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.

You should also note that many providers who contract with a Medi-Cal managed care plan may not accept straight 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 accept fee-for-service or straight Medi-Cal. If they do, they can bill your primary insurance before billing the amount not covered to Medi-Cal.

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. It depends on what type of Medi-Cal coverage you have and whether the provider is contracted with Medi-Cal, and there are some exceptions, as Director of Health Plan Advocacy Leslie Lobel explains in this clip.

Under straight Medi-Cal, some medical services 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 straight Medi-Cal, 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 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:

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).