Does Medi-Cal Reimburse Out-of-Pocket Expenses?

Medi-Cal can reimburse you for out-of-pocket expenses you paid for covered medical or dental care, as long as you were eligible for Medi-Cal on the date of service and you file a claim within the deadline. The process is called a Conlan claim, and it runs through the California Department of Health Care Services. Once your paperwork is complete, DHCS takes up to 120 days to process it, and the actual check may arrive later than that depending on how the provider responds.¹

When Your Expenses Qualify

Whether you can get money back depends on when the service happened relative to your Medi-Cal application. DHCS recognizes three separate periods.

The retroactive period covers the three months immediately before the month you applied. This window only applies if you specifically requested retroactive coverage and your county eligibility worker or Medi-Cal approved it. If you never asked for retro coverage during your application, expenses from before you applied are not reimbursable, even if you were financially eligible at the time. This trips people up more than any other rule. If you skipped that request, contact your county eligibility worker before you file a Conlan claim for pre-application bills.

The evaluation period runs from the date you submitted your application to the date your Medi-Cal card was issued. For services on or after February 2, 2006, the provider must have been enrolled as a Medi-Cal provider on the date of service.

The post-approval period is anything after your card was issued. This is where you land if a provider billed you by mistake despite active coverage, or if you were charged excess copayment or excess share-of-cost amounts. Again, the provider must have been enrolled with Medi-Cal on the date of service.¹

Across all three periods, you must have been both medically and financially eligible for Medi-Cal in the month the bill was incurred. DHCS checks your income and asset status for that specific month.

What Kind of Care Is Covered

Reimbursement is available for services inside the Medi-Cal benefit package that meet the standard of medical necessity. That includes emergency room visits, physician services, outpatient surgery, prescription drugs, hospital stays, mental health treatment, substance use treatment, lab work, and dental care under Denti-Cal. Medical and dental expenses both go through the same Conlan claim procedure.¹

Services that fall outside Medi-Cal’s covered benefits will not be reimbursed, regardless of the amount you spent. A dental procedure not included in Denti-Cal or an elective cosmetic procedure would not qualify. If the service is one that normally requires prior authorization, you will need documentation from your provider showing the care was medically necessary.²

How Much You Get Back

The refund amount depends on whether DHCS can recover the money from the provider who charged you. There are three outcomes.

In a voluntary provider reimbursement, the provider agrees to refund the full amount, usually sending the payment directly to you.

In an involuntary provider reimbursement, the provider refuses. Medi-Cal recovers the full amount from the provider through recoupment, then pays you the full amount you spent.

In a Medi-Cal rate reimbursement, DHCS cannot recover from the provider at all, because the provider has closed, was never enrolled in Medi-Cal, or does not bill enough for recoupment to work. Medi-Cal then pays you directly, but only up to the Medi-Cal allowed rate for that service. The Medi-Cal rate is usually lower than what you paid, so you may not get everything back.

Reimbursement will never exceed what you actually paid.¹

Documents You Need to File

A complete Conlan packet includes several items. Missing any of them will slow or sink your claim.

Medi-Cal Claim Form for Beneficiary Reimbursement (DHCS 4521). Fill it out online on the DHCS website and print it, or print a blank copy and complete it by hand.
Payee Data Record (STD 204). This state form is required by law before DHCS can issue any payment, and it is the one people most often forget.³
A copy of your Medi-Cal Beneficiary Identification Card (BIC).
Proof of payment: a copy of a canceled check (front and back), a receipt from the provider, evidence of electronic payment, or a copy of a money order. If you paid cash and have no bank record, a written declaration may be accepted to supplement your other documents.
An itemized billing statement showing the date of service, the specific services or service codes, and the amount you paid out of pocket.
Prior authorization documentation from your provider, if the service is one that would normally require Medi-Cal authorization.

Send photocopies of your supporting documents, not originals. DHCS specifically asks for copies of proof of payment and billing statements.²

Where to Send the Claim

There is no online submission option. You can complete the forms electronically on the DHCS website, but the finished packet has to be printed and mailed to:

Beneficiary Service Center
P.O. Box 138008
Sacramento, CA 95813-8008

This address handles reimbursement claims for medical, mental health, substance use treatment, and in-home supportive services. Dental claims covered under Denti-Cal go to the same address as part of the Conlan process.²

Send it by certified mail with a return receipt. That gives you a tracking number and proof of delivery, which matters if a dispute about timeliness comes up later.⁴

Filing Deadline

Your packet must be received within one year from the date of service, or within 90 days from the date your Medi-Cal card was issued, whichever comes later. Miss that window and DHCS will deny the claim regardless of how strong it otherwise is.⁵

The 90-day-from-card-issuance rule matters most when your application took a long time to process. If your card arrived eleven months after a service, you still have 90 days from the card date to file, even though the one-year mark from the service is closing in. Do not wait to gather perfect documentation if a deadline is near. File what you have and send supplemental documents later if DHCS requests them.

How Long Processing Takes

Once DHCS has a complete and valid claim, processing takes up to 120 days.⁵

During that window, DHCS reviews your eligibility for the date of service, confirms the service is a covered benefit, and contacts the provider. If the claim is approved, the provider gets a letter and has 30 days to respond with a voluntary refund. If the provider does not respond within those 30 days, DHCS issues the reimbursement check to you directly, typically seven to eight weeks after that 30-day window closes. Real-world turnaround from submission to check-in-hand can stretch well past 120 days once you add in the provider response period and mail time.⁵

Watch your mail throughout the process. DHCS may send correspondence asking for additional information or clarification, and responding promptly keeps the claim from stalling.

If DHCS Denies Your Claim

A denial is not necessarily the end. You will receive a written notice explaining the reason, the specific regulation or criteria used, and any clinical rationale. You can request free copies of everything DHCS used to make the decision.⁶

If you disagree, you have 90 days from the date of the notice to request a state fair hearing through the California Department of Social Services.⁷

At a fair hearing, you can represent yourself or bring anyone you choose to help, whether that is a lawyer, a relative, or a friend. You present your evidence and challenge the basis for the denial. Common reasons for denial include missing documentation, services outside the covered benefits list, or eligibility gaps for the date of service. If the denial came from incomplete paperwork rather than a fundamental eligibility problem, resubmitting a corrected claim may be faster than a hearing.⁸

Two Situations That Do Not Go Through Conlan

If you have both Medicare and Medi-Cal, providers are not allowed to bill you for Medicare deductibles and coinsurance. Those costs go to Medi-Cal, not to you. If a provider collected deductible or coinsurance payments from you, they must refund the money once they receive Medi-Cal’s payment confirmation. Qualified Medicare Beneficiaries cannot be billed any residual amounts at all. If a provider refuses to refund Medicare cost-sharing amounts you paid, you can address that through the Conlan process or by filing a complaint with your Medi-Cal managed care plan.⁹

If your monthly share of cost was set too high and later reduced retroactively, you may be owed a refund for the excess. That refund does not go through the Conlan system. Your county office prepares a Share of Cost Medi-Cal Provider Letter (form MC 1054), which you give to the provider. The provider must then reimburse you the full adjustment amount, up to what you actually paid, after they receive Medi-Cal’s payment for the difference. If your share of cost dropped to zero after the adjustment, the only way to recover the money is directly from the provider using the MC 1054 letter.¹⁰

1
Department of Health Care Services. Medi-Cal Out-of-Pocket Expense Reimbursement (Conlan)
2
Department of Health Care Services. Medi-Cal Claim Form For Beneficiary Reimbursement (DHCS 4521)
3
Department of Health Care Services. Payee Data Record (STD 204)
4
DHCS.ca.gov. Online Conlan Claim Forms
5
DHCS – CA.gov. Conlan Frequently Asked Questions
6
DHCS. NOABD – Payment Denial Notice
7
CDSS.ca.gov. State Hearing Requests
8
Cornell Law School – Legal Information Institute. Fair Hearing Related to Denial, Termination or Reduction in Medical Services
9
Medi-Cal. Medicare/Medi-Cal Crossover Claims Overview
10
DHCS Medi-Cal Eligibility Procedures Manual. 12C – Processing Cases When a Share of Cost Has Been Reduced Retroactively