What should I know about balance billing?
If you have both Medicare and Medi-Cal coverage (meaning you are a dual eligible beneficiary), health care providers (like a doctor or hospital) cannot charge you for any part of your health care costs. This means that you cannot be charged for co-pays, co-insurance or deductibles. If a health care provider does charge you, this is called balance billing, and it is against the law.
This applies to both your Medicare and Medi-Cal providers. This applies even if you are in a health plan for your Medicare or Medi-Cal benefits. This does not apply to all prescription drugs. This also does not apply to dual eligible beneficiaries who pay a share of their Medi-Cal cost every month.
Balance billing is illegal under both federal and state law. Dual eligible beneficiaries should never be charged any amount for services covered under Medicare or Medi-Cal.
What should I do if I am billed by a health care provider?
If you have been billed by a health care provider for a Medi-Cal or Medicare covered service, do not pay the bill. Contact L.A. Care Medicare Plus immediately to resolve the issue at 1-833-522-3767 (TTY: 711).
You should also contact your health care provider and tell them that you should not have been billed because you receive Medi-Cal. Providers must take immediate actions to fix the issue once they know that you have Medi-Cal.
They must stop the bill collection process, and they must work with credit reporting agencies to correct any issues caused by billing you. If you or your health care provider want to understand more about balance billing or have questions about what actions to take, you can also call the the Office of the Ombudsman 1-888-452-8609. This call is free. Monday through Friday, between 8:00 a.m. and 5:00 p.m.
For more information on LA Care Medicare Plus, dual eligibility or balance billing, please visit DHCS Integrated Care for Duals website.
Billing dual eligible beneficiaries violates Federal law as outlined in Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997.
2023 D-SNP SMAC: D-SNP Contractor and its contracted providers are prohibited from imposing cost-sharing requirements on Dual Eligible Members that would exceed the amounts permitted under the California Medicaid State Plan, Section 1852(a)(7) of the Act, and 42 CFR section 422.504(g)(1)(iii).