Making the Most of Medi-Cal
Medi-Cal can be an invaluable source of health care coverage for children with disabilities. However, it can be difficult to navigate the enrollment process, especially if your child already has private insurance coverage. Our Public Benefits Specialist, Lisa Concoff Kronbeck, talked with us about how best to use Medi-Cal as secondary coverage and to pay for expenses that aren’t covered by private insurance, such as durable medical equipment (DME) or consumable medical supplies.
California offers several programs that allow people with disabilities to qualify for Medi-Cal regardless of their household income. Children with developmental disabilities who are Regional Center clients may qualify through the institutional deeming waiver for individuals with developmental disabilities.
What are the benefits of Medi-Cal eligibility?
Medi-Cal does much more than pay for health care costs. It can also qualify your child for certain government benefits that they could not access otherwise. For example, an individual must be enrolled in Medi-Cal to receive In-Home Supportive Services (IHSS). Vision and dental care are also covered under Medi-Cal.
Medi-Cal also helps to pay for a number of Regional Center services, including:
- Tailored day services
- Skilled nursing
- Behavioral supports
- Housing and vehicle modifications
- Day programs
- Social skills therapy
- Neuropsychology services
Types of Medi-Cal
Every eligible child will automatically be enrolled in fee-for-service coverage once Medi-Cal is approved. Within a few weeks of enrollment, Medi-Cal Health Care Options will mail out an informational packet requesting that you choose a managed care plan for your child. If your child already has private insurance coverage, they will typically stay enrolled in fee-for-service Medi-Cal (see below for instructions). If Medi-Cal will be your child’s only insurance, you need to choose a plan in most cases (some very medically complex children may be eligible for an exemption, but this is not common). If your private insurance is an HMO that is also offered by the county, you can ask about enrolling in that managed plan alongside your private plan. For example, families who have private insurance through Kaiser may also assign their Medi-Cal to Kaiser if it is available in their county.
County-managed Medi-Cal plans
Children without a private primary insurer will be enrolled 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.
Managed care plans can 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, 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 or “straight” Medi-Cal
Families who already have health insurance coverage for their child can still benefit from Medi-Cal. If your child qualifies through an institutional deeming waiver, Medi-Cal may be used as a secondary insurance to pay certain expenses that your primary health insurance doesn’t cover, including:
- Consumable medical supplies, such as incontinence supplies, tracheostomy supplies, and g-tube feeding supplies
- Durable Medical Equipment (DME)
- Physical, occupational, and speech therapy when medically necessary
- Augmentative/alternative communication (AAC) devices
- Home nursing care
- Behavioral health treatment
- Ambulance and emergency room services
First, you need to make sure your physician, facility, or service accepts straight Medi-Cal. If they do, they can bill your primary insurance before billing the amount not covered to Medi-Cal. 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.
Note that providers who accept a Medi-Cal managed care plan may not accept straight Medi-Cal.
How to use straight Medi-Cal as secondary insurance
There are several extra steps you must take to use straight or fee-for-service Medi-Cal as secondary coverage:
- When enrolling 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. Ask them for the website where you can submit proof of your current insurance.
- After this, your child will stay on straight Medi-Cal.
If you accidentally end up enrolled in a managed plan when you want to stay on fee-for-service, it can be fixed in two steps:
- Contact Health Care Options, explain the situation, and provide proof of other coverage.
- Then contact the Managed Care Ombudsman; they should be able to expedite the change once it's in the system.
Finding a doctor who accepts straight Medi-Cal
Because straight Medi-Cal is meant to support your primary insurance, not override it, your best bet is to first search for providers who accept your primary insurance. Then, ask them if they accept straight Medi-Cal. Your primary insurance provider should have a list of providers and hospitals that are in-network, which can act as a great starting point for finding the right doctor. If you have a specific doctor in mind, you can directly ask them if they accept straight Medi-Cal.
The future of fee-for-service or straight Medi-Cal
When deciding between fee-for-service or managed plans, consider that it may be harder to find certain types of health care providers with straight Medi-Cal. Lisa Concoff Kronbeck tells us that many small clinics don’t accept fee-for-service Medi-Cal, so it’s harder to find therapists, for example. Straight Medi-Cal is more often accepted at larger hospitals and universities.
Currently, it is difficult to coordinate Medi-Cal with private plans, and the general policy stated by the Department of Health Care Services (the state agency that oversees Medi-Cal) is that recipients with private coverage are not supposed to enroll in a managed care plan. As Concoff Kronbeck points out, “In order to get anything covered by the managed care plan, you have to see a doctor within the HMO and get a referral for everything, and that tends not to work very well with private insurance.” Medi-Cal has plans to increase the availability of managed plan options for families with private coverage in 2022.
What about coordination of benefits (COB)?
Coordination of benefits (COB) refers to the method that insurance plans use to provide coverage and determine payment responsibilities for someone who is covered by more than one health plan. Concoff Kronbeck explains that Medi-Cal is the payer of last resort, which means that all other health plans you may be enrolled in — such as private insurance, a group health plan, or a managed care organization — are legally required to pay for their part of any claims before Medi-Cal will pay anything.
To ensure that insurance companies and other third parties pay their share, the state collects information on any pre-existing coverage whenever someone applies for medical assistance. If a family applies for Medi-Cal for their child, they must also show proof of any insurance or other third party coverage.
How to handle treatment authorization requests
Some medical, pharmacy, or dental 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.
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.