Traditional MedicareReimbursementMedium impact
25-975 Change to Coordinating Medi-Cal Benefits When Medicare is Primary
Health Net·CA·Reimbursement
Effective date
Nov 1, 2025
We identified it
Jun 20, 2026
Summary
Effective November 1, 2025, CalViva Health will stop using Medicare's Explanation of Benefits (EOMB) rate to coordinate Medi-Cal benefits when Medicare is primary. Instead, providers' contract rates will determine Medi-Cal reimbursement when no established Medi-Cal rate exists.
Action Required
Before November 1, 2025: Billing team should review contract rates with CalViva Health to understand how dual Medicare/Medi-Cal claims will be reimbursed. Update billing system documentation to reflect new coordination methodology for professional and outpatient claims. Contact CalViva Health at 888-893-1569 with questions about contract default pricing.