Medi-Cal fee-for-service (FFS) is a way of receiving Medi-Cal benefits where your doctors bill the state directly for each service they provide, rather than being paid through a managed care health plan. Instead of being assigned to a specific health plan with a fixed provider network, you can visit any Medi-Cal provider who accepts FFS patients. The state then pays that provider for each individual visit, test, or procedure.
How Fee-for-Service Works
In a fee-for-service arrangement, there’s no middleman health plan between you and the state. When you see a doctor, get lab work, or receive any covered medical service, the provider submits a claim to California’s Department of Health Care Services (DHCS). The state’s claims processing system reviews the claim, and if everything checks out, it generates a payment to the provider.
Providers can submit claims electronically through the Medi-Cal Provider Portal, which speeds up processing, or on paper. They have six months from the date of service to file. Claims submitted seven to nine months late are only reimbursed at 75% of the normal amount, and claims filed ten to twelve months late drop to 50%. After twelve months, claims are denied entirely.
FFS vs. Managed Care
Most Medi-Cal beneficiaries today are enrolled in managed care plans rather than FFS. The practical differences come down to provider choice, coordination, and extra services.
- Provider access: With FFS, you can see any Medi-Cal provider who accepts it. In managed care, you choose from doctors within your plan’s network.
- Care coordination: Managed care plans coordinate your benefits for you, helping connect you to specialists, follow-ups, and preventive care. In FFS, your benefits are generally not coordinated, so you’re navigating the system more independently.
- Community Supports: Managed care plans offer services called Community Supports, which can include things like housing transition assistance and medically tailored meals. These are not available through FFS.
Neither option changes what Medi-Cal covers. The core benefits are the same. The difference is in how those benefits are delivered and who manages the process.
Who Still Uses Fee-for-Service
California has been moving most Medi-Cal beneficiaries into managed care plans, and since January 2023, many people who were previously in FFS have been required to transition. But certain groups remain in FFS or can choose it.
People who have both Medicare and Medi-Cal (sometimes called “dual eligibles”) may qualify for FFS Medi-Cal in specific situations, such as those with a share of cost who live in the community rather than a nursing facility. Native Americans can choose fee-for-service Medi-Cal. Enrollees in the Program of All-Inclusive Care for the Elderly (PACE) and residents of California veterans’ homes also fall outside mandatory managed care enrollment.
If you’re being transitioned from FFS to a managed care plan, you have the right to request continuity of care with your current providers. This means you can keep seeing a doctor you’ve been treated by in the past 12 months, even if they’re not in your new plan’s network, while you establish care with in-network providers.
Services Paid Through FFS Even in Managed Care
Even if you’re enrolled in a managed care plan, some of your Medi-Cal benefits are “carved out” and paid through the fee-for-service system. The biggest example is pharmacy.
Starting January 1, 2022, California moved all outpatient pharmacy benefits from managed care to FFS under a program called Medi-Cal Rx. The goal was to lower the state’s drug costs, standardize what’s covered statewide, and give members access to a broader network of pharmacies. So regardless of whether you’re in a managed care plan, your prescriptions filled at a pharmacy are processed through the FFS system. Certain drug categories like HIV/AIDS medications, antipsychotics, and drugs for substance use disorders were already carved out of managed care before this transition and continue to be billed through FFS.
Dental care is another carved-out service. In all but two California counties, dental benefits are delivered through the FFS system (historically known as Denti-Cal). Sacramento County requires enrollment in a dental managed care plan, and Los Angeles County gives beneficiaries the option to join one. Everywhere else, you see any dentist who accepts Medi-Cal FFS.
Finding a Provider Who Accepts FFS
DHCS maintains an online FFS provider listing through its GIS Data Hub, where you can search for doctors, specialists, and other providers near you who accept fee-for-service Medi-Cal. You can filter by location and provider type. Since FFS doesn’t come with a plan directory or member services line the way managed care does, this tool and calling providers directly are your main options for confirming who will see you.
Provider availability can be a real challenge with FFS. Medi-Cal reimbursement rates are lower than what many doctors receive from private insurance or even Medicare, and some providers limit how many FFS Medi-Cal patients they take. If you’re having difficulty finding a provider, contacting your county’s Medi-Cal office can help point you in the right direction.