The California Medical Assistance Program (Medi-Cal or MediCal) is California's Medicaid program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138% of federal poverty level. Benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, dental (Denti-Cal), vision, and long term care and supports. Approximately 13.3 million people were enrolled in Medi-Cal as of January 2018, or about one-third of California's population; in Tulare County and Merced County, more than 50% of county residents were enrolled as of September 2015.
Medi-Cal provides health coverage for people with low income and limited ability to pay for health coverage, including the aged, blind, disabled, young adults and children, pregnant women, persons in a skilled nursing or intermediate care home, and persons in the Breast and Cervical Cancer Treatment Program (BCCTP). People receiving federally funded cash assistance programs, such as CalWORKs (a state implementation of the federal Temporary Assistance for Needy Families (TANF) program), the State Supplementation Program (SSP) (a state supplement to the federal Supplemental Security Income (SSI) program), foster care, adoption assistance, certain refugee assistance programs, or In-Home Supportive Services (IHSS) are also eligible.
As a means-tested program, Medi-Cal imposes asset limits on certain prospective enrollees. Medi-Cal individuals who receive long-term supportive services or who enroll in Medi-Cal through certain disabilities are subject to asset tests. This limit depends on the number of individuals being considered for coverage; for one enrollee, this limit is $2,000, while for two enrollees, the limit is $3,000. Each additional individual being considered results in an additional $150 of permitted assets, up to a total of ten individuals covered. If applicants possess property whose total value exceeds the allowed amount, they are required to reduce ("sell down") their assets through activities such as purchasing clothes, purchasing home furnishings, paying medical bills, paying a home mortgage, paying home loans, and paying off other debts.
Beginning in 2014 under the Patient Protection and Affordable Care Act (PPACA), those with family incomes up to 138% of the federal poverty level became eligible for Medi-Cal (pursuant to 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII)), and individuals with higher incomes and some small businesses may choose a plan in Covered California, California's health insurance marketplace, with potential federal subsidies.
Legal permanent residents (LPRs) with a substantial work history (defined as 40 quarters of Social Security covered earnings) or military connection are eligible for the full range of major federal means-tested benefit programs, including Medicaid (Medi-Cal). LPRs entering after August 22, 1996, are barred from Medicaid for five years, after which their coverage becomes a state option, and states have the option to cover LPRs who are children or who are pregnant during the first five years. Noncitizen SSI recipients are eligible for (and required to be covered under) Medicaid. Refugees and asylees are eligible for Medicaid for seven years after arrival; after this term, they may be eligible at state option.
Nonimmigrants and unauthorized aliens are not eligible for most federal benefits, regardless of whether they are means tested, with notable exceptions for emergency services (e.g., Medicaid for emergency medical care), but states have the option to cover nonimmigrant and unauthorized aliens who are pregnant or who are children, and can meet the definition of "lawfully residing" in the United States. Special rules apply to several limited noncitizen categories: certain "cross-border" American Indians, Hmong/Highland Laotians, parolees and conditional entrants, and cases of abuse.
Medi-Cal health benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, dental (Denti-Cal), vision, and long term care and supports.
California is one of a few US states that provide Medicaid dental benefits to adults. But given Denti-Cal's bare-bones coverage and the widespread absence of participating dentists in the program, a patchwork of supplemental programs has grown up to fill in some of the gaps, including Federally Qualified Health Centers (FQHC), a designation that refers to hundreds of health clinics and systems that operate in underserved, low-income and uninsured communities that private-practice dentists tend to avoid, and the state's First 5 county commissions, which are funded by tobacco sales taxes, as well as a sprinkling of county-funded dental care.
Medi-Cal fee for serviceEdit
As of January 2018, 2.5 million people were enrolled in Medi-Cal fee-for-service, representing about 19% of all enrollees. In the fee-for-service arrangement, health care providers submit claims to the Medi-Cal program for services rendered.
Medi-Cal managed careEdit
Most beneficiaries receive Medi-Cal benefits from contracted Medicaid managed care organizations. As of January 2018, 10.8 million people were enrolled in a Medi-Cal managed care plan, representing about 81% of all enrollees.
- a County Organized Health System (COHS) model, with one health plan per county,
- a "two plan model" with one community health plan and one commercial health plan in the county,
- a geographic managed care model with multiple plans per county,
- a regional managed care model with 1-2 commercial health plans in many counties,
- and unique one-county models in San Benito and Imperial counties.
In Denti-Cal, the majority of beneficiaries are covered through fee-for-service arrangements, where the state pays dentists directly for services, instead of the managed care model. However, more than 879,000 Denti-Cal enrollees do receive dental care through managed care plans started as experimental alternatives in the 1990s: in Los Angeles County where managed care plans are optional for beneficiaries, and in Sacramento County where they are mandatory. Eleven counties had no Denti-Cal providers or no providers willing to accept new child patients covered by Denti-Cal: Del Norte, Tehama, Yuba, Sierra, Nevada, Amador, Calaveras, Alpine, Mariposa, Mono and Inyo counties. Delta Dental, operating in the same building as DHCS' Denti-Cal division, enrolls dentists into DentiCal, processes claims by dentists, pays dentists and authorizes treatments, and also handles customer service operations and outreach.
Medi-Cal is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS), while the county welfare department in each of the 58 counties is responsible for local administration of the Medi-Cal program. C4Yourself and CalWIN are statewide online application systems that allows you to apply for benefits.
Federal law mostly consists of the Social Security Amendments of 1965 which added Title XIX to the Social Security Act (42 U.S.C. § 1396 et seq.), and state law mostly consists of California Welfare and Institutions Code (WIC) Division 9, Part 3, Chapter 7 (WIC § 14000 et seq.). Federal regulations are mostly found in Code of Federal Regulations (CFR) Title 42, Chapter IV, Subchapter C (42 C.F.R. 430 et seq.) and state regulations are contained in California Code of Regulations (CCR) Title 22, Division 3 (22 CCR § 50005).
Medi-Cal costs are estimated at $73.9 billion ($16.9 billion in state funds) in 2014-15. For comparison, the entire California state budget in 2014-2015 is $156 billion, of which about $108 billion was general funds (not allocated for special expenditures, such as bonds).
Partnership for Long-Term CareEdit
The Long-Term Care Partnership Program is a public-private partnership between states and private insurance companies, designed to reduce Medicaid expenditures by delaying or eliminating the need for some people to rely on Medicaid to pay for long-term care services. To encourage the purchase of private partnership policies, long-term care insurance policyholders are allowed to protect some or all of their assets from Medicaid spend-down requirements during the eligibility determination process, but they still must meet income requirements. The California Partnership for Long-Term Care Program links Medi-Cal and the In-Home Supportive Services program, i.e., private long-term care insurance and health care service plan contracts that cover long-term care for aged, blind, or disabled persons.
Indigent health programsEdit
Since 1933, California law has required counties to provide relief to the poor, including health care services and general assistance. County indigent medical programs can be categorized as California Medical Service Program (CMSP) and Medically Indigent Service Program (MISP) counties. There are 34 CMSP counties and 24 MISP counties. The CMSP county programs are largely managed by the state, whereas MISP counties manage their own programs with their own rules and regulations. Many patients from both the CMSP and MISP county programs transitioned to Medi-Cal when the Patient Protection and Affordable Care Act took effect in 2014.
- California Department of Healthcare Services. "What are the Medi-Cal Benefits?". Retrieved 2017-05-29.
- California Department of Health Care Services (January 2018). "Medi-Cal at a Glance. Most Recent Reported Month – January 2018" (PDF). Retrieved 2018-06-18.
- California Department of Health Care Services (January 2016). "Proportion of California Population Certified Eligible for Medi‐Cal By County and Age Group – September 2015" (PDF). Medi-Cal Statistical Brief. Retrieved 2017-05-29.
- O'Shaughnessey 2001, footnote 1, pg. 25.
- O'Shaughnessey 2001, p. 6.
- [dead link]
- "Medi-Cal General Property Limitations" (PDF). State of California — Health and Human Services Agency. Retrieved 24 Feb 2018.
- RL33809 Noncitizen Eligibility for Federal Public Assistance: Policy Overview (Report). Congressional Research Service. December 12, 2016. This article incorporates text from this source, which is in the public domain.
- Little Hoover Commission (April 2016), Report #230: Fixing Denti-Cal
- California Department of Health Care Services. "Medi-Cal Utilization and Fee-For-Service (FFS) Expenditures". Retrieved 2018-06-18.
- "Medi-Cal Managed Care Models" (PDF). Retrieved 6 December 2014.
- "Medi-Cal Managed Care Division". Retrieved 6 December 2014.
- WIC § 10800 et seq.
- 22 CCR § 50004
- "County Offices to Apply for Medi-Cal". California Department of Health Care Services. Retrieved 18 January 2013.
- "Consolidating California's Statewide Automated Welfare Systems" (PDF). California Legislative Analyst's Office. 13 February 2012. Retrieved 18 January 2013.
- "Medi-Cal Managed Care Health Plan Directory".
- Governor's Office Enacted 2014-2015 California State Budget summary., June 2014
- Dicken, John E.; Friday, Krister; Mamerow, Clare; Theisen-Olson, Anna (2005-10-11). GAO-05-1021R Overview of the Long-Term Care Partnership Program (Report). Government Accountability Office. This article incorporates text from this source, which is in the public domain.
- WIC § 22000 et seq. WIC § 12300 et seq. 22 CCR § 58000 et seq.
- "Understanding County Health Services in California: A Brief Overview". Institute for Local Government. Retrieved 2012-10-08.
- "County Programs for the Medically Indigent in California" (PDF). California HealthCare Foundation. 1 October 2009. Retrieved 20 November 2012.
- DHCS Research and Analytic Studies Division. "MEDI-CAL MONTHLY ELIGIBLES TREND REPORT FOR JANUARY 2014" (PDF).
- O'Shaughnessey, Molly (2001). Losing Ground: Declining Medi-Cal Enrollment After Welfare Reform. California Budget Project.
- Official website
- BenefitsCal.org (to apply) from the County Welfare Directors Association
- California Medical Assistance Program in the California Code of Regulations
- Medicaid State Plan information for California
- State Waivers for Medicaid program in California