MedicaidReimbursementHigh impact
22-933 Medi-Cal Member Balance Billing is Prohibited
Health Net·CA·Reimbursement
We identified it
Jun 20, 2026
Summary
CalViva Health prohibits balance billing for Medi-Cal members beyond their copayment and coinsurance. Providers cannot charge Medi-Cal members any additional fees, and when Medicare is primary with Medi-Cal secondary, providers must not charge copayments, coinsurance, or deductibles as these are covered by the Medi-Cal plan.
Action Required
Immediately: Billing team must review all Medi-Cal member accounts to ensure no balance billing occurs beyond copayments and coinsurance. Update billing system rules to prevent charging Medi-Cal members for covered services. For dual-eligible members (Medicare primary/Medi-Cal secondary), configure system to not charge copayments, coinsurance, or deductibles. Train staff on proper fee-for-service Medi-Cal billing when managed care coverage is on hold. Violation of these rules may result in contract violations and legal issues.