FAQs About Out-of-State Providers under Medi-Cal

It’s common for members of the same family to qualify for different health coverage programs. For example, one member may be eligible for premium assistance tax credits through Covered California while another is enrolled in Medi-Cal. Medi-Cal offers both managed care plans and fee-for-service. If a member selects a Managed Care Plan (MCP), they must use doctors in the MCP’s network.

What is a Temporary Out-of-State Provider?

Millions of Californians qualify for free or low-cost health coverage through Medi-Cal, the state version of the federal Medicaid program. Most enrollees are assigned to a managed care plan in their county and use their health plan card to access medical services. More than 400 hospitals, doctors, pharmacists, dentists and other providers are in Medi-Cal’s network. Many people with disabilities or chronic conditions need help getting to the doctor or picking up medications. These are called long-term services and supports. In California, a patchwork of programs provides these services. Find out how these programs work and who qualifies for them.

In addition to providing health care, the Medi-Cal program also tries to recover the cost of its benefits from some beneficiaries. This information is intended to explain how that works in California. The Medi-Cal benefits help millions of children and families with incomes below the poverty level get the necessary health care. 

What is a Permanent Out-of-State Provider?

California has a large Medicaid program called Medi-Cal which provides health care coverage for low-income individuals and families. The Affordable Care Act (ACA) expanded the program to include people with slightly higher incomes who otherwise would not qualify. Medi-Cal covers doctor visits, hospital stays, prescriptions, dental and vision care and more. The county human services departments are responsible for administrating the program locally. Most of the program is administered through Managed Care Plans (MCP). Some Medi-Cal recipients must contribute a certain monthly sum to their medical costs, much like a private health insurance deductible. The MCPs contract with providers to provide services through their networks, so most recipients must use doctors and facilities in the MCP they’re enrolled in. There are some exceptions to this rule, including telehealth providers. During the COVID-19 pandemic, nearly all states waived their usual licensing requirements to allow telehealth practitioners licensed in another state to treat residents of their State. Some States have also passed legislation allowing telehealth providers to treat out-of-state patients as long as they are referred by a licensed provider in the State where the patient lives.

How Do I Become a Temporary Out-of-State Provider?

If you have limited income and resources, you may be eligible to receive health care services through the Medi-Cal program. The program covers various medical needs, including health services, dental, vision, hearing, and more. You can apply for Medi-Cal anytime throughout the year through Covered California or your county human services department. The number of people enrolled in the program is increasing a great deal. It is largely due to the program expansion that California opted into under the Affordable Care Act to allow more people to qualify for Medi-Cal regardless of their family size, disability, income, and assets. Millions of Californians live with disabling conditions and require assistance to complete daily tasks. There is a patchwork of programs that provide this help, which is collectively known as long-term services and supports (LTSS). Medi-Cal covers many of these costs. The LTSS program is complicated, and it’s important to understand how these programs work together. These fact sheets offer an overview, including how they’re financed and administered.

How Do I Become a Permanent Out-of-State Provider?

Medi-Cal is California’s public health insurance program which provides needed medical services for low-income families with children, seniors and people with disabilities. It is financed equally by the federal and State governments. The program is administered at the local level by county human services departments. Some people who receive Medi-Cal must pay a monthly dollar amount toward their medical expenses, similar to a private health insurance deductible. These payments are called Share of Cost (SOC). A provider must certify that a recipient has paid or become obligated to pay their SOC online through the Medi-Cal eligibility verification system before billing for services. Claims submitted for services rendered to recipients whose SOC needs certification are denied.

A health care practitioner must obtain a full license from the State where they practice to be considered a Medi-Cal provider. In some states, this process can be expedited if the healthcare practitioner is licensed in another state participating in the Interstate Medical Licensure Compact. UMSU students who wish to provide telehealth services should contact the State of Florida for information on obtaining a license to practice in that State. If you’re interested in becoming a Medi-Cal provider, the first step is to apply for licensure in your State. You must meet some requirements, such as passing an exam and having a valid medical license. 

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Manisha Puri

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