Medi-Cal Fee-for-Service is California’s original payment model, where the Department of Health Care Services pays providers directly for each covered visit or procedure instead of routing your care through a managed care plan. Most of the roughly 15 million Medi-Cal beneficiaries in the state are now in managed care, so Fee-for-Service applies to a narrower set of situations: people with a monthly Share of Cost, people in temporary or retroactive eligibility windows, some former foster youth, and specific services that the state carves out and pays for separately regardless of your plan.
Who Is Still in Fee-for-Service
Share of Cost Beneficiaries
If your income is above the standard Medi-Cal limits but you still qualify on other grounds, the state assigns you a monthly dollar amount you must pay toward medical expenses before Medi-Cal coverage activates that month. It works like a deductible that resets on the first of every month.1Medi-Cal. Medi-Cal Fee-for-Service Share of Cost
Providers verify your progress by running clearance transactions through the state’s eligibility system, and several may be needed before your Share of Cost is fully certified. Once you meet the amount, you receive full-scope Medi-Cal benefits for the rest of that calendar month, and the state pays providers directly for remaining covered care.1Medi-Cal. Medi-Cal Fee-for-Service Share of Cost Because your eligibility can turn on and off from one month to the next, the state keeps you in FFS rather than assigning you to a managed care plan.
Presumptive Eligibility
Certain hospitals and community clinics can grant you immediate, temporary Medi-Cal coverage on the spot if you appear to meet income requirements. Hospital Presumptive Eligibility relies on your own statements about income and household size, with no pay stubs or tax returns required at the time.2Department of Health Care Services. Hospital Presumptive Eligibility A separate program covers pregnant individuals, with qualified providers granting temporary coverage for prenatal care, pregnancy-related prescriptions, and abortion services while a formal application is pending.3Department of Health Care Services. Presumptive Eligibility for Pregnant People
You are not in a managed care plan during either presumptive window, so the state pays providers directly through FFS. If your full application is later approved, you will typically be enrolled in a managed care plan going forward. If it is denied, the temporary coverage still stands, and you will not be billed retroactively for services the state already authorized.
Retroactive Coverage for Past Bills
Once you are approved, Medi-Cal can pay for covered services you received during the three months before your application date, provided you would have been eligible when the care was delivered. Federal regulations require states to offer this three-month retroactive window.4Medicaid and CHIP Payment and Access Commission. Medicaid Retroactive Eligibility Changes under Section 1115 Waivers Since those visits happened before any plan enrollment, providers submit the claims directly to the state for FFS reimbursement. You generally contact your county social services office within one year of the month of service to request this coverage.5Department of Health Care Services. How Do I Apply
One caveat: California has previously obtained federal waivers that can narrow retroactive eligibility for certain populations or services. Pregnant women, children, aged or disabled individuals, and former foster youth are typically protected from these waivers and keep full retroactive coverage.4Medicaid and CHIP Payment and Access Commission. Medicaid Retroactive Eligibility Changes under Section 1115 Waivers
Former Foster Youth
If you were in foster care and enrolled in Medi-Cal on your 18th birthday, federal law requires the state to continue your coverage until age 26, with no income test and no asset test.6Medicaid.gov. Medicaid and CHIP FAQs Coverage of Former Foster Care Children California provides this group full-scope, zero Share of Cost benefits. Managed care enrollment is generally optional for former foster youth, so you can stay in FFS if you prefer, unless you live in a county with a County Organized Health System, where managed care is mandatory. That flexibility matters because former foster youth often move between counties, and FFS avoids switching managed care networks each time your address changes.
This eligibility category also takes priority over other Medi-Cal groups. If you qualify both as a former foster youth and under the adult expansion group, you must be enrolled under the former foster youth category, which carries stronger protections.6Medicaid.gov. Medicaid and CHIP FAQs Coverage of Former Foster Care Children
Services Paid Through Fee-for-Service Even If You Are in Managed Care
Some categories of care are carved out of managed care plans and paid separately, so you can be enrolled in a managed care plan for most needs and still receive certain services through FFS or a related state system.
Outpatient Prescriptions Through Medi-Cal Rx
Since January 1, 2022, nearly all outpatient pharmacy benefits have run through Medi-Cal Rx, a centralized FFS program. Pharmacies bill the state’s contracted administrator directly for your medications rather than going through your managed care plan. In practice, you can fill prescriptions at any Medi-Cal Rx enrolled pharmacy regardless of your managed care plan’s network. The program covers prescription drugs, certain medical supplies, and enteral nutrition products when billed on a pharmacy claim.7Medi-Cal Rx. Transitioning Medi-Cal Pharmacy Services from Managed Care to FFS FAQs
Specialty Mental Health and Substance Use Treatment
Specialty mental health services are carved out from managed care and administered by county Mental Health Plans, which handle intensive psychiatric services including crisis intervention and inpatient psychiatric care. Your managed care plan covers milder mental health needs, such as outpatient therapy for common conditions. County behavioral health departments also manage substance use disorder treatment under a similar arrangement.
California Children’s Services
Children with certain serious medical conditions, such as congenital heart defects or cancer, may qualify for California Children’s Services. Historically, CCS operated as a carve-out: routine wellness care went through the child’s managed care plan while specialized treatment for the qualifying condition was billed separately. California has been transitioning some counties to a Whole Child Model that folds CCS into managed care, so whether your child’s CCS care runs through FFS now depends on which county you live in.
What Has Moved Out of Fee-for-Service
Some situations that used to run through FFS no longer do, and older material online can leave the wrong impression. The most significant recent change involves skilled nursing facilities. Before 2023, in most counties, managed care plans only covered the first month or two of a nursing facility stay, after which residents moved to Medi-Cal FFS for long-term care.8Department of Health Care Services. Skilled Nursing Facility Long-Term Care Carve-In Frequently Asked Questions As of January 1, 2023, managed care plans cover long-term care in skilled nursing facilities.
Managed care also now operates in all 58 California counties. In earlier years, some rural counties lacked the provider networks for managed care, and FFS was the default there. That is no longer the case. And since 2023, dual eligible beneficiaries (people with both Medicare and Medi-Cal) are required to enroll in Medi-Cal managed care plans in all counties, so the secondary Medi-Cal payment that used to run through FFS now goes through the managed care plan.9Department of Health Care Services. Medi-Cal Managed Care and Medicare Crossover Billing Provider Toolkit
California law explicitly emphasizes managed care as the primary delivery method for Medi-Cal, with FFS preserved for specific situations.10California Legislative Information. California Welfare and Institutions Code 14000
Finding a Provider Under Fee-for-Service
The practical challenge with FFS is finding providers willing to see you. FFS reimbursement rates are significantly lower than what Medicare or private insurance pays for the same services. Nationally, Medicaid FFS rates average about 72 percent of Medicare rates, and the gap is wider for some specialties. Fewer physicians accept new Medicaid patients than accept Medicare or privately insured patients.
You are not limited to a plan network in FFS, so technically you can see any provider in the state who accepts Medi-Cal. But that pool is smaller than it sounds, especially for specialists. If you are struggling to find a provider, your county social services office or the DHCS ombudsman can help locate participating providers in your area. Community health centers and federally qualified health centers are often the most reliable access points for FFS beneficiaries because they are built to serve Medicaid populations.
You Cannot Be Balance Billed
Whether you receive care through FFS or a managed care plan, Medi-Cal providers cannot bill you for the difference between their standard charges and what Medi-Cal pays. This federal prohibition on balance billing applies across both Medicare and Medicaid. A provider who agrees to accept Medi-Cal patients accepts the state’s reimbursement rate as payment in full.
This matters most in FFS, where you may see providers outside any managed care network. If a provider accepts you as a Medi-Cal FFS patient and delivers a covered service, the state’s payment plus any small copayment you owe is the final bill. A separate federal protection applies if you are in the Qualified Medicare Beneficiary program: no Medicare provider can bill you for Medicare deductibles, coinsurance, or copayments, and providers who violate this must refund any amounts collected and face sanctions.11Centers for Medicare and Medicaid Services. Beneficiaries Dually Eligible for Medicare and Medicaid If a provider sends you a bill above what Medi-Cal covers or refers you to collections, contact the Department of Health Care Services to report the violation.
Appealing a Denied FFS Claim or Eligibility Decision
If a Medi-Cal FFS claim is denied or you disagree with an eligibility determination, you can request a state fair hearing. You generally have 90 days from the date the notice of action is mailed to file your request.12California Department of Social Services. State Hearing Requests
The process is more direct than the managed care route. With a managed care plan, you typically first appeal to the plan and then escalate to a state hearing if that response is unsatisfactory. In FFS, you go straight to the state hearing because there is no intermediary plan.
Federal regulations guarantee several procedural rights during a fair hearing. You can examine your full case file and any documents the state plans to use, bring witnesses, present evidence, and cross-examine anyone testifying against your claim.13eCFR. Fair Hearings for Applicants and Beneficiaries You can represent yourself or have a lawyer, family member, or friend represent you.
One protection catches many beneficiaries off guard. If you request a hearing before the effective date of a reduction or termination of services, the state generally must continue those services until a decision is reached. This “aid paid pending” rule can prevent gaps in care while your case is being decided. The state must issue a final decision within 90 days of receiving your hearing request.13eCFR. Fair Hearings for Applicants and Beneficiaries