The short answer is “No”. Both state and federal law provide broad protections to Medicare/Medi-Cal dual eligible individuals, and prohibit billing a Medi-Cal patient in most circumstances. California’s Department of Health Care Services takes the position that a physician should first bill Medicare and then bill the Medi-Cal program for the services. Only if the services are thereafter deemed non-covered, can the physician bill the patient directly. The Social Security Act prohibits Medicare providers from “balance billing” Medicare beneficiaries who have secondary coverage under a state Medicaid plan. Additionally, California laws prohibit providers who know a patient is eligible for Medi-Cal from seeking reimbursement from the patient for covered health care services. If a physician knowingly and willfully violates the law, he or she faces the possibility of exclusion for 5 years from all programs that receive federal funding. This means physicians could lose their ability to see patients covered under Medicare, Tricare, Medi-Cal, Medicare Advantage (managed care) programs and Federal Workers’ Compensation. In addition to exclusion, the federal government may impose civil monetary penalties. Private insurers may also take action based on exclusion from federal programs. Despite the existing prohibitions, there are some physicians who are still billing Medi-Medi patients. Again, physicians may be subject to sanctions for failure to follow these billing requirements, and CMS has indicated that it may start conducting more frequent audits to address this practice. The only time Medi-Cal pays as a secondary payor is if :

  • the patient hasn’t yet met their deductible and the services are applied to the deductible by the primary payor, or
  • for a handful of codes where Medi-Cal pays more than Medicare.
  • In these two instances, Medi-Cal will pay up to the Medi-Cal reimbursement rate. Otherwise, Medi-Cal doesn’t pay anything as a secondary and the physician is required to write off the balance. Physicians who are not currently enrolled in the Medi-Cal program may enroll as Medi-Medi-only providers. More information about how to enroll as a Medi/Medi provider, referred to as “Crossover Only,” and a link to the Crossover Only Provider Form (MC0804) can be found on the Medi-Cal website. Reference: 

    • Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997
    • California Welfare & Institutions Code §14019.4
    • Crossover Only Enrollment FAQs –
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