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Posted by on May 10, 2016 in Jenna MacRae, News Affecting Seniors |

News Affecting Seniors

Do Medicare/Medi-Cal “Dual Eligibles” Have to Pay Co-pays?


By Jenna MacRae

Many low-income individuals have both Medicare and Medi-Cal (sometimes referred to as Dual Eligibles). Dual Eligibiles should never be charged co-pays or deductibles for their Medicare Part A (hospital) and Part B (medical) benefits. In fact, it is illegal for a doctor, hospital or other Medicare health-care provider to “balance bill” and charge dual eligibles Medicare co-pays.1

Despite both federal and state law1 , EL&A’s HICAP Program has heard dual eligibles report that they frequently pay these co-pays. Surprisingly, many health-care providers do not know or are confused by these laws. Some dual eligibles have been told, “we don’t accept Medi-Cal, but you can see the doctor if you pay 20%.” Others simply receive a bill in the mail. Either way, these charges are illegal. Whether the dual eligible uses Original Medicare or is enrolled in a Medicare Advantage Plan, such as a Medicare HMO,2 they should not be charged co-pays for Medicare Part A or Part B services.

In contrast, dual eligibles are responsible for paying co-pays in order to pick up their Medicare Part D prescription medications at a pharmacy. (The Part D Extra Help Program will significantly reduce these medication co-pays.)

Some low-income individuals have Medicare and Medi-Cal with a Share-of-Cost. In this case, their Medi-Cal benefits and protections do not begin until they have met their monthly share-of-cost. Therefore, beneficiaries who have not yet met their monthly share-of-cost are responsible for their Medicare co-pays and deductibles.3

If you would like to learn more about these “balance billing” protections, find out if these protections apply to you, think that you have been a victim of “balance billing”, or if you would like to review your Prescription Drug Coverage, contact HICAP at 800-434-0222 to speak with a Registered Medicare Counselor.

1   42 U.S.C. 1396a § 1902(n)(3)(B) and Cal. Welf. & Inst. Code § 14019.4

2   Beneficiaries enrolled in a Medicare Advantage Plan must follow their Plan’s rules for network providers.

3   Cal. Welf. & Inst. Code § 14019.4(g)