Traditional MedicareReimbursementMedium impact
25-974 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, Health Net/Community Health Plan of Imperial Valley will change how they coordinate Medi-Cal benefits when Medicare is primary. Instead of using Medicare's Explanation of Benefits rates, they will now use providers' contract rates to determine Medi-Cal reimbursement when no Medi-Cal rate is available.
Action Required
Before November 1, 2025: Billing team must review and understand contract default pricing rates with Health Net/Community Health Plan of Imperial Valley for professional and outpatient claims. Update billing system logic to expect reimbursement based on contract rates rather than Medicare EOMB rates when coordinating Medicare-primary/Medi-Cal-secondary claims. Contact plan at 833-236-4141 for questions about contract rates.