The California Medical Assistance Program (Medi-Cal or MediCal) is California 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. It is jointly administered by the California Department of Health Care Services (DHCS) and the federal Centers for Medicare and Medicaid Services (CMS), with many services implemented at the local level by the counties of California. Approximately 12.5 million people were enrolled in Medi-Cal as of May 2015, or about 32.4% of California's population.
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.
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.
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.
Many of these benefits for most beneficiaries are contracted out to Medi-Cal Managed Care organizations. Dental benefits and mental health benefits for the seriously and persistently mentally ill are universally excluded from Medi-Cal Managed Care contracts. California has several models of Medi-Cal Managed Care which are designated at the county level.
California is one of a few US states that provide Medicaid dental benefits to adults. 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, although more than 879,000 beneficiaries do receive dental care through managed care plans in Los Angeles County and Sacramento County.
Many of these benefits for most beneficiaries are contracted out to Medi-Cal Managed Care organizations. Dental benefits and mental health benefits for the seriously and persistently mentally ill are universally excluded from Medi-Cal Managed Care contracts. California has several models of Medi-Cal Managed Care which are designated at the county level: County Organized Health System (COHS) model with one health plan per county, "Two Plan Model" with one community health plan and one commercial health plan in the county, Geographic Managed Care model with multiple plans per county, Regional Managed Care model, with 1-2 commercial health plans in many counties, and two unique one-county models in San Benito and Imperial counties. As of July, 2015, 9.7 million Medi-Cal enrollees were enrolled in a Medi-Cal Managed Care Plan, representing about 78% of all enrollees.
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. More than 879,000 Denti-Cal beneficiaries 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. 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. 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. Eleven California 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.
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).
Medi-Cal with the assistance from the Robert Wood Johnson Foundation created The California Partnership for Long-Term Care. The goal is to protect Californians from being forced to spend everything they have worked for on long-term care, and to prevent or delay dependence on Medi-Cal.
Indigent health programs
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. "Medi-Cal Eligibles 24-Month Trend at May 2015 - Advance Counts" (PDF). Medi-Cal Statistical Brief. Retrieved 22 August 2015.
- O'Shaughnessey 2001, footnote 1, pg. 25.
- O'Shaughnessey 2001, p. 6.
- http://www.dhcs.ca.gov/services/medi-cal/Documents/Benefits%20Chart.pdf, California DHCS summary of Medi-Cal Benefits.
- Little Hoover Commission (April 2016), Report #230: Fixing Denti-Cal
- "Medi-Cal Managed Care Models" (PDF). Retrieved 6 December 2014.
- "Medi-Cal Managed Care Division". Retrieved 6 December 2014.
- California Department of Healthcare Services (July 2015). "Medi-Cal Managed Care Enrollment Report" (PDF). DHCS. Retrieved 22 August 2015.
- 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
- The California Partnership
- "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.
- BenefitsCal.org (to apply) from the County Welfare Directors Association
- Official website
- California Medical Assistance Program in the California Code of Regulations
- Medicaid State Plan information for California
- State Waivers for Medicaid program in California