25-973 Change to Coordinating Medi-Cal Benefits When Medicare is Primary

Date: 09/17/25

Providers’ contract rates will be used to determine claim reimbursement when no Medi-Cal rate is available

Effective November 1, 2025, Health Net will update how Medi-Cal benefits are coordinated when Medicare is the primary payer. This change follows a recent review of our coordination methodology. Providers’ contract rates will be used to determine the Medi-Cal allowed amount when no Medi-Cal rate is available.

What’s changing

Since 2016, Health Net has used the Explanation of Medicare Benefits (EOMB) rate to coordinate benefits when a Medi-Cal allowable amount was not available. This approach will be discontinued. Instead, contract default pricing will be applied.  

Impacted claim types

This update applies to:

• Professional claims
• Outpatient claims

Calculation examples

When Medicare is the primary payer and Medi-Cal does not have an established allowable amount, the providers’ contract rate will be used to determine reimbursement.

• Medicare has an allowable, Medi-Cal does not:
  → Use contract default pricing as the Medi-Cal allowable amount
• Neither Medicare nor Medi-Cal has an allowable:
  → Use contract default pricing as the Medi-Cal allowable amount

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6001. Behavioral health providers can call 844-966-0298.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.