Balance Billing

What If I Get a Bill from a Health Care Provider?

You may receive medical bills that you do not have to pay.

 

What should I know about improper billing?

If you have Medicare and Medi-Cal, health care providers and health plans cannot charge you for your health care costs. Charging you is called improper or “balance billing” and is illegal under both federal and state law.

  • Under the law, you cannot be charged for co-pays, co-insurance, or deductibles.

There are some exceptions, see below.

What should I do if I get a bill from by one of my health care providers?

  1. Do not pay the bill.
  2. Contact your health plan immediately to deal with the issue. You can also contact HICAP at 1-800-434-0222 to get help.
  3. Contact your health care provider and tell them that you have Cal MediConnect and should not be billed. Tell them to contact your health plan.

Your provider must take immediate action to fix the issue. They must stop the bill collection process and work with credit reporting agencies to correct any issues caused by billing you.

The only times they are allowed to charge you are:

  1. Co-pays for prescription drugs.
  2. Some Medi-Cal beneficiaries need to pay a monthly share-of-cost. For information about share-of-cost, call your county Medi-cal office.

Why would a provider bill me for services?

As the responsibility for paying for your health care switches from Medicare to your Cal MediConnect health plan, providers may bill you incorrectly. The state is educating providers to prevent incorrect billing.

To learn more about balance billing, you or your provider can call the Cal MediConnect Ombudsman at 1-855-501-3077.

DHCS Releases a New Provider Bulletin on Continuity of Care and Billing

In order to ensure that beneficiary transitions into Cal MediConnect are smooth and do not result in disruptions in care, the CCI continuity of care policy provides beneficiaries in Cal MediConnect plans with the right to continue seeing non-participating physicians for a limited period of time.

DHCS has developed a Provider Bulletin explaining how current out-of-network physicians can continue seeing Cal MediConnect beneficiaries and the process for billing the correct entity for payment. It also provides information to help combat balance billing.

DHCS encourages stakeholders to forward this bulletin to providers who may need the information about these important protections.

OneCare Connect webinar for OC Providers

Click Here to Register

The Coordinated Care Initiative: Key Information on OneCare Connect and Balance Billing for Orange County Physicians

Description

This webinar is designed for physicians and will cover the Coordinated Care Initiative (CCI) and the programs within the initiative including Cal MediConnect, known as OneCare Connect in Orange County.

The CCI is a new program designed to help provide extra support for low-income seniors and people with disabilities in California, including those who are dually eligible for Medicare and Medi-Cal.

Webinar topics include:

1. Overview: How the CCI is changing health care for dual eligible patients;

2. Continuity of Care: How to keep seeing your patients if they join OneCare Connect;

3. Care Coordination: How OneCare Connect can help support physicians in coordinating care for patients, including in-home and community-based services;

4. Billing Processes: How billing works under the CCI for patients that join OneCare Connect and for those who remain in fee-for-service Medicare and join the CCI for Medi-Cal services.

Speakers – Rita Cruz Gallegos, Provider Outreach Strategist, Harbage Consulting / Provider Relations Department at CalOptima 

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Fact Sheets

ALL | CONSUMERS| PROVIDERS | ADVOCATES

Medi-Cal News: Free Transportation Benefit! – Created by the LA Communications Workgroup (September 2018)
Your Dental Services Through Medi-Cal – created by Asian Americans Advancing Justice, Justice in Aging, and the California Pan-Ethnic Health Network (September 2018)
Non-Emergency Medical Transportation (NEMT) vs. Non-Medical Transportation (NMT) (March 2018)
About Our Outreach (March 2021)
Continuing Your Care After You Join a Cal MediConnect Plan (September 2016)
Cal MediConnect Enrollment Assistants (September 2015)
Beneficiaries Enrolled in Regional Centers and State Developmental Centers (July 2015)
CCI Eligible Populations Table (June 2020)
Beneficiaries with In-Home Supportive Services (IHSS) (January 2015)
Beneficiaries on the Assisted Living Waiver (October 2017)
Beneficiaries in NF/AH and IHO Waivers (March 2018)
The CCI and Behavioral Health Coordination (August 2013)
The CCI and 1915(c) Waivers (May 2013)
Beneficiaries in the Multipurpose Senior Services Program (MSSP) (May 2013)
Beneficiaries with Developmental Disabilities (May 2013)
CCI Beneficiary Protections (August 2012)

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CONSUMERS

Cal MediConnect Benefits (June 2018)
Balance Billing Consumer Fact Sheet created by Justice in Aging (November 2016)
Continuity of Care for Beneficiaries (September 2016)
CCI Basics for Consumers created by Disability Rights California (October 2019)
Beneficiaries with HIV / AIDS with Both Medicare and Medi-Cal or Medi-Cal Only (October 2015)
Your Rights and Responsibilities as a Plan Member (May 2015)
Balance Billing (May 2015)
Beneficiaries and the PACE Program (November 2020)

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PROVIDERS

CCI Provider FAQ (August 2016)

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ADVOCATES

CCI Advocates Guide V6 – created by Justice in Aging (December 2017)
Two Cal MediConnect Eligibility Protections: Deeming and Aid Paid Pending (December 2017)
Caregivers, Community-Based Organizations, and the CCI (September 2020)
Social Worker Resource Guide (August 2018)
Empowering Dual Eligible Consumers through Information Exchange: Early Lessons from Cal MediConnect – courtesy of Personal Assistance Services Council (March 2015)
DMHC Brochures and Fact Sheets Available

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To view county specific fact sheets, videos, and presentations, visit our county pages.

To view materials in other languages, visit our language pages.

Managed Long Term Services and Supports (MLTSS)

If you do not join Cal MediConnect, you must have a Medi-Cal health plan or a PACE plan. Below is more information about Medi-Cal health plans.


What is a Medi-Cal Managed Care Plan?

It’s a health plan that coordinates your Medi-Cal services, including provider visits, medicines, hospital care, and special equipment to help you manage your health.

Your Medicare benefits will not change.

When you have a Medi-Cal Managed Care plan, your Medicare benefits won’t change. You can still go to your Medicare hospitals and providers. They do not have to contract with your Medi-Cal plan to be paid for the services they provide you. If you have problems getting your Medicare services, call 1-800-MEDICARE (1-800-633-4227) immediately. Or call your Medicare Advantage plan, if you are in one.

What will change when I have a Medi-Cal Managed Care plan?

The Medi-Cal Managed Care plan will manage all of your Medi-Cal benefits, including your long-term services and supports (LTSS). If you receive Medi-Cal covered medical supplies and equipment, such as insulin pumps, the plan must provide these. However, you must get them from suppliers in the plan’s network.

These services will NOT change when you have a Medi-Cal Managed Care plan:
• In-Home Supportive Services (IHSS)
• Community-Based Adult Services ( CBAS)
• Multipurpose Senior Services Program (MSSP)
• Nursing facility services
You always have the right to hire, fire, and manage your IHSS providers.

Will I be charged for my Medi-Cal LTSS or my Medicare services?

You should not receive a bill for your LTSS or Medicare services. Billing you is called “balance billing.” This is illegal under both federal and state law. You are not responsible for co-pays, co-insurance, or deductibles for any Medi-Cal or Medicare services you receive.
There are only two exceptions when it is OK for you to be billed:
• Your Medicare prescription drug plan can charge you drug co-pays at the Extra Help level.
• Some people with Medi-Cal pay a monthly share-of-cost.
For information about share-of-cost, call your county Medi-Cal office.

Click here to find health plan contact information for your county.