Medi-Cal is the nation’s largest state Medicaid program. California recently changed the rules to require that most recipients enroll in managed care plans. Families will receive a mailer with their county’s Medi-Cal plan options. They must choose a health plan within 30 days, or Medi-Cal will select one.
Coverage for Children
Children in California with low incomes and needs, including disabilities, can get free or low-cost health insurance through Medi-Cal. They can also get various long-term care services, such as dental and vision care. They can use the same network as people with private insurance, meaning they can access the same doctors and benefits. Children with special health care need to face particular challenges, making insurance coverage, affordability, and benefit package contents especially important. Unlike other populations, their families often cannot afford private insurance, and many states have implemented programs to help them. It is particularly true of states that cover children with special needs through Medicaid and the Children’s Health Insurance Program (CHIP).
State and federal rules allow for broad flexibility to make sure that children with disabilities and their families can obtain the services they need. For instance, some states raise the financial eligibility threshold to 300% of the SSI level ($28,584 per year for an individual or $22,998 for a family of three), and other states mandate that counties implement different disability-related paths to Medicaid eligibility. As a result of these policies, in addition to providing full-scope benefits for children through its Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit, Medi-Cal also manages the health care of children with disabilities and their families using various managed care models. Over 10 million Medi-Cal beneficiaries, or three-quarters of the program’s population, are enrolled in managed care plans.
Coverage for Adults
For adults, California has shifted nearly 5 million Medi-Cal beneficiaries to managed care through the SPD transition and Dual Demonstration, expanding the scope of services covered under their contracts. The expansions include adult day health services, mental health services, and, in seven demonstration counties, certain long-term services and supports. This rapid growth strained the capacity of managed care plans to recruit and train providers, reinforce call centers, and rapidly implement new systems for screening, referrals, quality improvement, claims processing, data management, and member engagement. As the State continues to move toward a large managed care system, it must improve its ability to assess and monitor quality. It will require a new way to measure the performance of plans and to ensure that they are accountable for the health outcomes of their members, as well as an efficient means to process applications and renewals.
Under the ACA, all individuals and families will receive an easy-to-read summary of their plan’s benefits and coverage in one booklet called a “Summary of Benefits and Coverage.” It will help consumers make “apples-to-apples” comparisons when shopping for health plans, including the Medi-Cal Advantage. You will also be able to use this booklet to compare your options for healthcare in the local marketplace, including Medi-Cal in San Bernardino, to compare private health insurance policies to discover the best offer that suits your requirements and price range.
Coverage for Seniors
If you are over 65 and have Medicare, you may be eligible for Medi-Cal Rx, which covers prescriptions that Medicare does not. You must sign up for this benefit during the open enrollment period each November through December at Covered California or a local Social Services agency. Both state and federal funds fund the program, free or low-cost to the person. Limits on income and assets determine eligibility. The program provides many benefits, including hospital, medical, dental and eye care services. In addition, the program offers long-term care and support services such as respite, personal emergency response systems, home health aides and nursing home transitions.
The program has recently moved from a fee-for-service model to a system that relies on risk-based managed care contracts. In this system, the state contracts with health plans that agree to provide a specified set of services in exchange for a monthly capitation payment for each enrollee. Plans are accountable and responsible for the quality of care delivered to beneficiaries.
Coverage for People with Disabilities
People with disabilities with high incomes and assets can still qualify for public health care coverage through the Medi-Cal program. The program is available to people whose income and property levels are too high for Medicare but too low to qualify for Social Security disability benefits. People who have been determined to be blind by a doctor, or disabled by the Social Security Administration, may qualify for Aged, Blind and Disabled Medi-Cal (ABD). ABD covers comprehensive preventative services, primary and specialty care, medical office visits, hospitalizations, prescription medications, and home and community-based long-term services and supports. The State also pays for short-term wage replacement through Disability Insurance (DI) and provides Paid Family Leave to allow working Californians to take time off work to care for a sick child, spouse or parent.
In the early managed care pilot programs, counties awarded contracts to health plans to provide various Medi-Cal services in specific counties or service areas. Since then, the State has expanded its contracts with private plan providers to cover all 58 counties, carved adult day health and mental health into managed care, and launched two demonstrations under Section 1115 waivers in seven large counties: the Dual Demonstration and the Managed Long-Term Services and Supports Demonstration. As a result of these and other innovations, in 2015, 77% of all California Medi-Cal beneficiaries were enrolled in managed care plans.
