Medical Exemption Requests (MERs)

Since 2011, California has been in the process of moving seniors and people with disabilities (SPDs) with Medi-Cal only and those eligible for both Medicare and Medi-Cal (dual eligible) into Medi-Cal managed care plans (Medi-Cal MCP) instead of traditional, regular, or fee-for-service Medi-Cal.

Disclaimer: This publication is legal information only and is not legal advice about your individual situation. It is current as of the date posted. We try to update our materials regularly. However, laws are regularly changing. If you want to make sure the law has not changed, contact DRC or another legal office.

1. What is a Medical Exemption Request (MER)?

Since 2011, California has been in the process of moving seniors and people with disabilities (SPDs) with Medi-Cal only and those eligible for both Medicare and Medi-Cal (dual eligibles) into Medi-Cal managed care plans (Medi-Cal MCPs) instead of Fee-For-Service (FFS) Medi-Cal.1 A Medical Exemption Request (MER) is a temporary request to be exempt from mandatory enrollment in a Medi-Cal plan and instead remain in FFS Medi-Cal. In other words, the point of a MER is for you to maintain access to your FFS providers who are not enrolled in a Medi-Cal MCP and to ensure your health is not put at risk during the transition to a Medi-Cal MCP.

MERs are granted on a very limited basis. This publication contains information about whether you are required to enroll in a Medi-Cal MCP and what criteria must be met to qualify for a MER.

2. Who is mandatorily enrolled in a Medi-Cal managed care plan (Medi-Cal MCP)?

With the launch of the California Advancing and Innovating Medi-Cal (CalAIM) initiative in January 2023, most individuals who have Medi-Cal are required to enroll in a Medi-Cal MCP, including those dually eligible for Medi-Cal and Medicare. There are very few exceptions to this mandate.2 Before CalAIM, enrollment was not mandatory for everyone and depended on various factors such as county of residence, population group, or if a person had other health care coverage.

3. Who Cannot Request a MER?

• You receive Community Based Adult Services (CBAS)/Adult Day Health Care.
• You live in a Single Plan or County Organized Health Systems (COHS) county.
• You have been enrolled in any Medi-Cal managed care plan for more than 90 days combined.
• Your doctor is part of a Medi-Cal MCP in the county where you live.
• Your plan of treatment is scheduled to begin AFTER your enrollment in the Medi-Cal managed care plan. 22 C.C.R. § 53887(a)(2)(B)(1)-(3), 22 CCR § 53923.5(b).

4. Who May Be Eligible For a MER?

• You have a complex medical condition (including third trimester of pregnancy), and
• Care for your complex medical condition is provided by a Medi-Cal FFS provider, and
• Your FFS Medi-Cal provider does not contract with any Medi-Cal plan in your county, and
• Your care and course of treatment cannot be changed without risk to your health, and
• You have not been a member of a Medi-Cal managed care plan for more than 90 days.

5. How Does the MER Process Work?

You and your doctor fill out a MER form (Form HCO 7101) and return it to the Department of Health Care Services (DHCS) through Health Care Options (HCO). DHCS staff then review your MER application and any evidence from your doctor to determine if you can be safely transitioned into a Medi-Cal MCP. In general, if you are only receiving maintenance care or being seen for routine follow up care you will not be granted a MER.

6. When Can a MER Be Requested?

When you receive the notice requiring you to select a managed care plan, you have 30 days to submit a MER. 22 C.C.R. § 53882(c). If you do not request a MER within 30 days, you will automatically be enrolled in a Medi-Cal MCP. 22 C.C.R. § 53882(d)(1). Note that even after you are enrolled in a Medi-Cal MCP following this 30-day window, you can still request a MER as long as you have not been in a Medi-Cal MCP for more than 90 days combined.

7. How to Request a MER?

If you want a medical exemption from enrolling in managed care, you and your doctor have to fill out the MER form (Form HCO 7101). You can also call Health Care Options (HCO) at 1-800-430-4263 to get a copy of the MER form mailed to you.

Call Health Care Options (HCO) if you have any questions. You or your doctor can also get help with your MER by calling the Medi-Cal managed care ombudsman at 1-888-452-8609, or sending an email to MMCDOmbudsmanOffice@dhcs.ca.gov. When you call the Office of the Ombudsman,3 make sure to keep notes of when you made the phone call and with whom you spoke. Maintaining notes of your conversations can help you correct mistakes.

TIPS to complete the MER:

The most common reason for a MER denial is that DHCS has determined that your condition is stable and that you can safely be moved to a Medi-Cal MCP. Your doctor will need to explain why, and provide evidence showing that, your condition is not stable.

It is important for your doctor to include information describing the ongoing medical supervision and/or complex medical treatment you receive, and why this prevents you from transferring into managed care right now. You should also be sure to include an explanation as to why you cannot be safely moved into managed care at this time. This information should come from a doctor that you see frequently and who has ongoing knowledge of your condition. The best evidence for this is a supporting letter from your doctor, which you include with your MER, and any medical records that your doctor feels are necessary to support the information.

8. Legal Standard for Exemption from Plan Enrollment

An eligible beneficiary may request to remain enrolled in FFS Medi-Cal based upon the exception for a complex medical condition requiring continuity of care for up to 12 months. 22 C.C.R. §§ 53887(a)(2), (a)(4).

The regulations state that an eligible beneficiary who is receiving FFS Medi-Cal treatment for services for a “complex medical condition,” from a physician, a certified nurse midwife, or a licensed midwife who is participating in the Medi-Cal program but is not a contracting provider of either plan (in a Two-Plan model county) in the eligible beneficiary’s county of residence, may request a medical exemption to continue FFS Medi-Cal for purposes of continuity of care. 22 C.C.R. § 53887(a)(2).

Conditions that meet the criteria for a “complex medical condition” include, among other conditions, that an individual has a complex and/or progressive disorder that requires ongoing medical supervision and/or the individual has been approved for or is receiving complex medical treatment for the disorder, the administration of which cannot be interrupted. 22 C.C.R. § 53887(a)(2)(A)(7).

Other conditions meeting the criteria for “complex medical condition” include:

• An eligible beneficiary is in the third trimester of pregnancy or has pregnancy complications.4
• An eligible beneficiary is under evaluation for the need for an organ transplant; has been approved for and is awaiting an organ transplant; or has received a transplant and is currently either immediately post-operative or exhibiting significant medical problems related to the transplant. Beneficiaries who are medically stable on post-transplant therapy are not eligible for exemption under this section.
• An eligible beneficiary is receiving chronic renal dialysis treatment.
• An eligible beneficiary has tested positive for HIV or has received a diagnosis of acquired immune deficiency syndrome (AIDS).
• An eligible beneficiary has been diagnosed with cancer and is currently receiving chemotherapy or radiation therapy or another course of accepted therapy for cancer that will continue for up to 12 months or has been approved for such therapy.
• An eligible beneficiary has been approved for a major surgical procedure by the FFS Medi-Cal program and is awaiting surgery or is immediately post-operative.
• An eligible beneficiary has a complex and/or progressive disorder, such as multiple sclerosis, hemophilia or sickle cell diseases, cardiomyopathy, or amyotrophic lateral sclerosis, that requires ongoing medical supervision and/or has been approved for or is receiving complex medical treatment for the disorder, the administration of which cannot be interrupted.5 22 C.C.R. § 53887 (a)(2)(A)(1)-(7).

9. If Your MER Is Granted

You may continue to see your FFS Medi-Cal doctor for up to 12 months. If you want to keep your MER beyond the approved time period, you will need to request a MER extension. This can only be done after 11 months of the existing MER’s start date and before the MER expires. DHCS requires you to request the extension to determine if your medical condition has stabilized. If your condition has stabilized, meaning you can be safely transferred to a managed care plan, your MER extension may be denied. Please be advised that MER extensions are granted very infrequently. Please also note that MER extensions are not possible if you move to a county that does not allow MERs (Single Plan or COHS counties).

10. Appealing a MER Denial

You have 90 days from the date of the denial letter to appeal. One strategy you might consider is waiting to file the MER towards the end of the 90-day period but before you are mandatorily enrolled into a Medi-Cal MCP. Waiting to file the MER towards the end of the 90-day period extends the time you are able to continue to see your FFS doctor. However, in order to continue to see your FFS Medi-Cal doctor, you must request the hearing before you are enrolled in a Medi-Cal MCP and ask for “aid paid pending.” Requesting “aid paid pending” means that you are requesting to continue in FFS Medi-Cal until the outcome of the hearing.

You can ask for a hearing and “aid paid pending” by writing using the hearing request form, which is included with the Notice of Action. You can say that you disagree with the decision, you want a fair hearing, and you are requesting aid paid pending. You can also request a hearing on-line, by phone, or by faxing or mailing a letter or the form to the address below:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430

Phone: 1-800-743-8525 or 1-855-795-0634

TDD: 1-800-952-8349
Fax: 1-833-281-0905

The hearing must be set within 30 days of the request and written notice of the time and place of the hearing must be sent at least 10 days before the hearing date. Cal. Welf. & Inst. Code § 10952.

TIPS to prepare for your MER hearing:

Review your file from DHCS: As soon as your MER is denied, you should request your file from DHCS. Once you receive your file from DHCS, review the evidence DHCS has to deny your MER. You have the right to know who at DHCS made a decision in your case. This will be a physician contracted with DHCS to review MERs. DHCS should tell you the professional qualifications of the reviewing physician, such as their area of specialty.

Review the Statement of Position: The Statement of Position must be available for you to review 2 business days before the hearing. The Statement of Position should have an explanation of why DHCS believes you can be safely transferred to managed care. It must contain an analysis of the medical records and any other supporting documents you provided with your MER.

Assemble your evidence: You will be able to present evidence that your condition is not stable enough to transfer to a managed care plan.

• The best way to do this is to get a letter from your doctor stating that you will suffer harmful health effects if you are forced to see a different doctor. Your doctor will want to provide evidence that your condition is unstable and that you cannot safely be transferred to a managed care plan physician. Supporting documents may include a treatment plan, notes from five most recent office visits, and current medical history and physical exam results.
• You can write your own Statement of Position, which can contain a response to DHCS’s Statement of Position.
• You can have witnesses. You can ask your doctor to appear at the hearing to testify on your behalf. You can also request that someone from DHCS be there, including the DHCS-contracted physician who reviewed your medical records and recommended to deny your MER.

If you need more time, then ask for an extension by contacting CDSS State Hearings Division (the contact listed above) to request that your hearing be postponed. A postponement request must be made before the day that the hearing is scheduled.

You can call the Health Consumer Alliance hotline at 1-888-804-3536 for additional information on MER and MER Hearings.

At your hearing, you will be able to present evidence that your condition is not stable enough to transfer to a managed care plan. You will want to argue that you are eligible for an exemption based on the fact that (1) you have a complex medical condition, (2) that requires ongoing care from your current physician, and (3) that transferring to a doctor in a managed care plan would cause deleterious medical effects. 22 CCR § 53923.5(b)(1)-(3).

If you receive an unfavorable decision,6 you can file for a rehearing (you have 30 days from the date you receive the decision). You can also file a Writ in superior court (you have a year from the date of the decision to do that). Whether or not you decide to appeal the unfavorable hearing decision, you are still entitled to continuity of care, and should ask for that from the Medi-Cal MCP you choose to enroll in (See Section 12).

11. If your MER Is Denied and You Do Not Appeal, Then You Can Request Continuity of Care or Authorization to See an Out-of-Network Provider

This section applies if your MER is denied and you decide not to appeal. If you are not granted a MER for your complex medical condition and you do not appeal, then you will have to join a Medi-Cal MCP. You can request to continue seeing your FFS Medi-Cal providers that are not part of the Medi-Cal MCP’s network by requesting what is called continuity of care.7 Health care providers that are not part of the Medi-Cal MCP’s network are called out-of-network providers. Out-of-network providers may include the FFS providers that you received care from prior to Medi-Cal MCP enrollment.

Request for Continuity of Care

Managed care plans must allow you to continue seeing your out of network providers for up to 12 months when:

• The managed care plan is able to determine that you have an ongoing relationship with the provider (you have seen the doctor at least once within the last 12 months); and
• Your provider is willing to accept the higher of managed care plan’s contract rates or FFS Medi-Cal rates; and
• The provider meets the managed care plan’s applicable professional standards and has no disqualifying quality-of-care issues. All Plan Letter 13-023 p. 1 (Dec. 24, 2013).8

For more information on continuity of care: Click to open DRC Continuity of Care publication. You may call your Medi-Cal MCP to request more information and help with obtaining continuity of care.

Out-of-Network Care

You may also be able to get out-of-network care when the care you need is not available from a provider in your Medi-Cal MCP’s network. Beneficiaries who are already in a Medi-Cal MCP but who require specific medical care that is not available in their Medi-Cal MCP’s network can request authorization to see an out-of-network provider. This type of agreement allows a beneficiary to remain in their managed care plan while also seeing a specific out-of-network provider for necessary care. This is an agreement between the managed care plan and the out-of-network provider to authorize: (1) payment at a specified rate (2) for identified services (3) during a specific time frame for your care.

To request authorization to see an out-of-network provider, contact your managed care plan directly. To get this authorization, you will need to show that you require care that is not available from any providers in the managed care plan’s network. It is helpful for your doctor to include information describing the ongoing medical supervision and/or complex medical treatment you receive, and why this requires treatment from an out-of-network provider.

If your request to see an out-of-network provider is denied, you can request review of the denial through your MCP’s grievance and appeal process.9

• 1. Managed care plans are groups of doctors, hospitals, clinics etc. (known as the “network”) who work together to take care of their members' health care needs. Once enrolled in a managed care plan, the member has to see providers that are in the network. Members choose a primary care physician (PCP) who they must go to first. The PCP can treat or refer members to a specialist within the network and sometimes outside of the network. Both Medi-Cal managed care and Fee-For-Service Medi-Cal are ways for the state to pay for health care services. With Fee-For-Service, the state pays providers directly for each service. With managed care, the state pays the managed care plan, which creates a more efficient payment model.
• 2. You may not have to enroll in a managed care plan if: you receive services from an Indian Health provider (Indian Health Program exemption form https://www.healthcareoptions.dhcs.ca.gov/content/dam/digital/united-states/california/ca-hco/documents/english/download-forms/request-for-indian-health-program-non-medical-exemption-from-plan-enrollment/MU_0003382_NonMedExemptionWEB1.pdf), you are in your third trimester of pregnancy, you get services through Foster Care, the Adoption Assistance Program, or Child Protective Services, you live in a veteran’s home, or you have certain complex health conditions. See the full list here: https://www.healthcareoptions.dhcs.ca.gov/en/who-must-enroll
• 3. For more information about the Office of the Ombudsman, https://www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx
• 4. See DHCS’s Frequently Asked Questions for more details: https://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/ENG-Medi-Cal-Expansion-FAQ.pdf
• 5. You must be able to provide evidence as to the reasons your current care cannot be interrupted. You should discuss the reasons with your doctor and have them record them in a supporting letter which you will include with your MER application. Refer to Section 6, above, for more information.
• 6. Please be advised that you may receive a favorable hearing decision from the Administrative Law Judge granting your request for a MER; however, DHCS has legal authority to reverse (“alternate”) the Judge’s decision and still deny your MER. If this results, then you have received an unfavorable hearing decision because your MER has been denied.
• 7. See, as outlined in All Plan Letter 17-007, p. 2 (May 11, 2017) (managed care plans “must ensure that all beneficiaries continue to receive medically necessary Medi-Cal services and ensure new enrollees are entitled to receive continuity of care with their existing providers for the completion of those services.”). http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2017/APL17-007.pdf
  “Managed Care Plans are required to consider a request for exemption from Managed Care Plan enrollment that is denied as a request to complete a course of treatment with an existing FFS or nonparticipating health plan provider under H&S Code § 1373.96, and in compliance with the Managed Care Plan’s contract with Department of Health Care Services and any other Department of Health Care Services continuity of care All Plan Letters. Managed Care Plans must ensure that all beneficiaries continue to receive medically necessary Medi-Cal services and ensure new enrollees are entitled to receive continuity of care with their existing providers for the completion of those services to the extent authorized by law. The beneficiary’s existing provider is identified by the National Provider Identifier on the Medical Exemption Request. Managed Care Plans must meet the continuity of care timeframes that are specified in H&S Code § 1373.96. This continuity of care policy is in addition to the extended continuity of care policy for Seniors and Persons with Disabilities established under All Plan Letter 11-019, Duals Plan Letter (DPL) 16-002 on continuity of care, APL 15-019 on continuity of care for Medi-Cal beneficiaries who transition into managed care, and other continuity of care APLs and DPLs.” (All Plan Letter 17-007, May 11, 2017.) Available at: http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2017/APL17-007.pdf
• 8. You can find the letter here: http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2013/APL13-023.pdf
• 9. For more information on Medi-Cal Managed Care Appeals and Grievances, https://www.disabilityrightsca.org/publications/medi-cal-managed-care-appeals-and-grievances