Medi-Cal managed care plans: enrollees with other health care coverage

The law aims to reduce administrative barriers when Medi-Cal pays eligible costs left unpaid by a member’s other insurance. It also clarifies when providers can bill managed care plans without joining their networks.

What the law does ​

• Requires the Department of Health Care Services to ensure noncontracted providers do not face billing requirements substantially greater than Medi-Cal fee-for-service requirements for unpaid allowable costs.
• Lets Medi-Cal fee-for-service providers bill managed care plans for covered services without becoming in-network when an enrollee has other coverage, excluding Medicare, and Medi-Cal is the payer of last resort.
• Allows plans to require an agreement for services needing prior authorization, services not covered by the other insurer, or qualifying continuity-of-care services.
• Bars providers from billing enrollees for amounts a plan does not pay above Medi-Cal fee-for-service rates or applicable service limits.
• Requires the department to clarify billing conditions and annually report implementation effectiveness to legislative health committees from 2027 through 2030.
• Allows implementation through departmental guidance, subject to needed federal approvals and available federal funding.

Who it affects ​

• Medi-Cal managed care enrollees who also have other health coverage.
• Medi-Cal fee-for-service and other noncontracted providers serving those enrollees.
• Medi-Cal managed care plans.

Context ​

Medi-Cal generally pays after other available health coverage.