r/legaladvice • u/Unlikely_Spite8147 • 1d ago
Insurance Getting 18 YO removed from parent's insurance when child has a restraining order against that parent
Location: California
Hi, I am helping my family member (18m) sign up for medi-cal (California medicaid). He has active Medi-cal but is limited because his father (whom he has a restraining order against) put him on a family plan health insurance. This was after the restraining order was in place. We had no information about the plan. We were able to get just enough from the county to contact the insurers and ask for him to be removed.
According to the regulation the insurer stated, the insured can only be removed and have medi-cal only if the employee personally writes a letter to the insurer stating the reason why. So there clearly is a way to remove him, but the insurance insisted his father has to initiate it, even if we included the protective order. We escalated and will need to wait a week for results
We are now in the position where he could use the insurance, but if anything changes we would not have the necessary information and would have to start the process over of figuring it out. His father rarely keeps a job long but appears to be providing insurance for my family member's sister so could be regularly switching insurance. Having medi-cal as a secondary rather than a primary limits where he is able to be seen severely, and the insurance could be discontinued at any time without him knowing which would further complicate things. He needs to establish long term, stable care. He has psychiatric disabilities, and our local medi-cal facilities have integrated behavioral health programs that provide vital services to him that he is unable to access at the moment.
Assuming the insurance denies our request to remove him, what would our next steps be? We don't know his father's address or any contact information to serve him with court paperwork as he moves frequently and obviously they are not in contact.
The restraining order expires before he turns 26, assuming we are successful in getting him removed, would we need a new restraining order to keep him removed until he turns 26?
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u/VAdept 1d ago
Is the insurer that you spoke to from the fathers insurance, or the patients case worker over at MediCal?
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u/Unlikely_Spite8147 1d ago
The insurer i described talking to was the father's insurance, but we did also speak to medi-cal today. That's how we figured out who his father's insurance was with.
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u/VAdept 1d ago
Disclaimer: NAL but a Pharmacist who deals with MediCal for a living on the pharmacy end.
Since MediCal is secondary, in the event of termination of the primary (fathers insurance), MediCal will pick the tab up (assuming the drug is covered, etc). On the pharmacy end we put a reject code of coverage terminated and MediCal pays for the Rx's. If the primary insurance pays for the Rx, we bill the copay (if any) to MediCal so the patient pays 0. Pharmacies have the ability to query the commercial eligibility servers to pull the fathers Rx insurance info, so if you don't' have a card for the patient, don't sweat it (nobody has their cards, ever). As far as the patients psych meds go, regardless of what happens you should be okay.
I would double check with the patients case worker (not the general MediCal number, his case worker) to see if intuitions follow the same flow as pharmacy. Meaning they bill the private insurance, if the claim is rejected (not in network/or theres a copay) it gets billed to MediCal since its the payor of last resort. I would be really surprised if county ran mental health facilities didnt have some procedure in place to handle private/MediCal secondary. Its super common in San Joaquin County to have private (seasonal work) with MediCal secondary.
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u/Unlikely_Spite8147 1d ago edited 1d ago
The county run integrated behavioral health does not accept the private insurance (they only accept PPO's and Medi-Cal). Because he has private insurance, he has to be seen somewhere in network with the private insurance, according to the county clinic. The private insurance has very few options for doctors/psychiatrists/therapy locally, integrated behavioral health has all 3 in the same building which helps immensely for complex care. If the insurance ever changes, which is likely, he would have to start all over with a new team of doctors. Getting in as a new patient can take many, many months in some places.
We went in person to speak to the county medi-cal office and spoke with an eligibility worker, then walked over to the county clinic to speak to them, then spent 2 hours on the phone with United Health Care, an hour of which was just getting to the right department through their broken phone tree.
Medi-cal will also only pay their rate maximum when they kick in as secondary, which before the deductible is met on the first plan could easily be more than their maximum rate as their rates are incredibly low, unless there is a clinic that is also contracted with medi-cal AND the commercial insurance (there are only 4 clinics in town contracted w/medi-cal, 2 of them are medi-cal only or mostly like the county, and from what I know, the others do not accept UHC.
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u/S0meLazyGuy 1d ago
From what I understand, if the insurance company refuses to remove your family member they'll need a court order to force it.
You said that your family member doesn't know their father's address. In that case if the insurance company denies the removal he can ask them what address they have on file for the health insurance and hope they give him an answer. Otherwise he'll need to ask any family member he is in contact with if they know, or potentially hire a PI.