26-1091 Balance Billing Medi-Cal Members is Prohibited
Date: 09/24/26
Avoid member complaints and potential disciplinary action
State and federal law prohibit billing or attempting to collect payment from a Medi-Cal member or anyone acting on the member's behalf, for services covered under the Medi-Cal program.¹ This requirement also applies under the Provider Participation Agreement (PPA).
Medi-Cal members are not responsible for payment unless a Medi-Cal share-of-cost applies.
Failure to comply with Medi-Cal requirements and the PPA may result in disciplinary action as outlined in the PPA.
What providers need to do
Physicians, practitioners and other providers must:
- Not bill Medi-Cal members for covered services.
- Not collect copayments, coinsurance, deductibles or other fees prohibited under Medi-Cal requirements.
- Bill fee-for-service (FFS) Medi-Cal for services provided to a Medi-Cal member whose managed care coverage has been placed on hold.
- Verify whether a member has other health coverage when determining billing responsibility.
For guidance on FFS Medi-Cal billing, visit the California Department of Health Care Services (DHCS) website.
Non-compliance
Penalties for non-compliance are outlined in the PPA. A pattern or practice of balance billing members may result in disciplinary action.
Prohibited billing practices
The following practices are prohibited:
- Billing members fees or surcharges for covered services, including copayments, deductibles or coinsurance.
- Requiring members to pay for a covered service denied or rejected by Health Net or the participating physician group (PPG).
- Charging Dual Special Needs Plan (D-SNP) members coinsurance, copayments, deductibles, financial penalties or any other amount.
- Requiring members to pay the difference between negotiated fees and the physician, practitioner or other provider's usual and customary fees.
When Medi-Cal is secondary coverage
When verifying eligibility, ask members whether they have additional health coverage.
If a member has Medicare or Commercial (Ambetter HMO/PPO or Employer Group HMO/POS and PPO) coverage as primary coverage and Medi-Cal as secondary coverage, providers must not charge the member copayments, coinsurance or deductibles. These charges are prohibited under Medi-Cal managed care requirements.
Provider appeals and disputes
If you disagree with the outcome of a claim, you may file a provider appeal or dispute with Health Net or the member's assigned medical group if you are affiliated with a PPG.
Information about the provider appeals/dispute process is available in the Provider Operations Manual within the Provider Library at Provider Library. Select Medi-Cal > Provider Manual > Appeals, Grievances and Disputes > Provider Appeals and Dispute Resolution.
Balance billing
Information about balance billing is available in the Medi-Cal Provider Operations Manual within the Provider Library. Select Medi-Cal> Provider Manual > Claims and Provider Reimbursement > Balance Billing.
Need help? Contact us
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.
1In accordance with Federal and State of CA 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 and California Welfare and Institutions Code section 14019.4 9 respectively, balance billing covered Medi-Cal enrollees is strictly prohibited.
This information applies to Physicians and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial County.