Haris Ashley
California's Medicaid program is called Medi-Cal, and it is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS). It is California's implementation of the federal 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 the federal poverty level. As of April 2024, Medi-Cal covered nearly 15 million people, with over a third of Californians relying on the program for health insurance coverage.
| Characteristics | Values |
|---|---|
| Name of California's Medicaid program | Medi-Cal |
| Who is it for? | Low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138% of the federal poverty level |
| Number of beneficiaries | Approximately 15.28 million as of September 2022 (or about 40% of California's population) |
| Benefits | 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 support |
| Cost | Estimated at $73.9 billion ($16.9 billion in state funds) in 2014–15 |
| Administration | Jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS). The county welfare department in each of the 58 counties is responsible for local administration. |
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What You'll Learn
California's Medicaid program is called Medi-Cal
Medi-Cal offers a range of health benefits, including 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 support. As of April 2024, Medi-Cal covered nearly 15 million people, with over a third of Californians relying on the program for health insurance coverage. The program's costs for 2014-2015 were estimated at $73.9 billion, with $16.9 billion coming from state funds.
Most beneficiaries receive Medi-Cal benefits from contracted Medicaid managed care organizations (MCOs). California has several models of managed care designated at the county level, including the County Organized Health System (COHS) model, the "two-plan model", the geographic managed care model, and the regional managed care model. In Denti-Cal, the majority of beneficiaries are covered through fee-for-service arrangements, where the state pays dentists directly for services.
California has generous standards for covering various Medicaid populations and has opted to use state funds to cover undocumented immigrants who meet the income requirements. The state had previously considered allowing undocumented immigrants to enrol in full-price private plans through Covered California, the state's health insurance exchange. While this did not come to pass, California passed SB10 during the 2016 legislative session, which called for allowing adults aged 19 and over to enrol in Medi-Cal without regard for immigration status. However, the final version of the bill instead requested a waiver from HHS to allow undocumented immigrants to enrol in unsubsidized qualified health plans through Covered California.
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Eligibility criteria for Medi-Cal
California's Medicaid health care program, Medi-Cal, provides medical services for children and adults with limited income and resources. Eligibility for Medi-Cal is determined by several factors, including income level relative to the Federal Poverty Level (FPL).
For adults, eligibility for Medi-Cal is granted if income is up to 138% of the FPL, while children are eligible if their income is up to 266% of the FPL. This eligibility criterion is known as Income-Based Medi-Cal.
Additionally, there are over 90 eligibility categories, each with its own rules and requirements. For instance, individuals receiving Supplemental Security Income (SSI) automatically qualify for SSI-Linked Medi-Cal. Aged or disabled individuals may be eligible for the Aged & Disabled Federal Poverty Level Medi-Cal program. If you are disabled and working, California's Working Disabled Program may be an option, which allows for a countable income of up to 250% of the FPL.
Another program, Aged, Blind, and Disabled – Medically Needy Medi-Cal, caters to aged, blind, or disabled individuals with incomes too high for other Medi-Cal programs. However, this program may require individuals to spend a certain amount of their own money before Medi-Cal starts paying for medical services, known as a "share of cost."
Since January 1, 2024, all immigrants in California who meet the program requirements can receive Medi-Cal coverage. This coverage is typically provided through a managed care program, where individuals have a primary care physician for most of their health needs.
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Applying for Medi-Cal
Medi-Cal is California's Medicaid health care program. It offers free or low-cost health services for eligible individuals and families with limited incomes and resources. Eligibility is determined by several factors, including income level relative to the Federal Poverty Level (FPL). For adults, eligibility income is up to 138% FPL, and for children, it is up to 266% FPL. Medi-Cal also provides free or affordable programs for immediate pregnancy coverage.
To apply for Medi-Cal, individuals can enroll in person, by phone, or online. Help is available in multiple languages, and guidance is offered by certified enrollment counselors, who are confidential and free of charge. The process begins with applying for the specific type of coverage needed with Covered California. Once the application is submitted, individuals will be notified of their eligibility and how the coverage program applies to them.
If an individual's circumstances change, they must report any household changes within 10 days to their local county social services office. To maintain Medi-Cal coverage, beneficiaries must renew their enrollment once a year on their original sign-up date. If an individual is no longer eligible for Medi-Cal, they should contact the service center within 60 days to discuss their options with Covered California.
It is important to note that Medi-Cal is not permanent, and ongoing eligibility is dependent on continued qualification based on the eligibility criteria. Therefore, individuals must ensure they provide accurate and up-to-date information during the application and renewal processes. By doing so, individuals can access and maintain their healthcare coverage through Medi-Cal in California.
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Benefits of Medi-Cal
In California, Medicaid is known as Medi-Cal. This program provides free or low-cost health care to those who qualify based on their income or resources. For adults, eligibility is up to 138% of the Federal Poverty Level (FPL) and for children, it's up to 266% FPL.
One of the key benefits of Medi-Cal is that it offers a comprehensive set of health services, ensuring that all enrollees have access to essential health benefits. These include doctor visits, hospital care, immunizations, pregnancy and maternity care, and even nursing home care. Additionally, mental health and substance use disorder services are covered, including behavioral health treatment, which is often overlooked in standard insurance plans.
Medi-Cal also provides prescription drug coverage, as well as access to rehabilitative and habilitative services, such as physical and occupational therapy, and the necessary devices. Laboratory services are also included, as are preventive and wellness services, which can help with chronic disease management. Children's oral and vision care are also covered under Medi-Cal, ensuring that children have access to essential health services from an early age.
For pregnant individuals, Medi-Cal offers immediate coverage to ensure that both mother and child receive the necessary care during and after pregnancy. This includes maternity and newborn care, as well as ongoing pediatric services for the child.
The benefits of Medi-Cal extend beyond just the scope of health services. The program also provides peace of mind and financial relief to those who may otherwise struggle to afford healthcare. With Medi-Cal, enrollees can focus on their health and well-being without the added stress of worrying about the cost of their medical care.
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Medi-Cal costs
California's Medicaid health care program, Medi-Cal, offers free or low-cost health care to children and adults with limited income and resources. Eligibility for Medi-Cal is determined by several factors, including income level. For instance, if an individual's income is up to 138% of the Federal Poverty Level (FPL), they may qualify for Medi-Cal.
If an applicant's income exceeds the threshold for free Medi-Cal, they may still be eligible for Medi-Cal with a shared monthly cost (formerly "Share of Cost"). This is similar to paying a deductible in private insurance. The shared monthly cost is the amount of money that must be paid each month towards medical services, supplies, or equipment before Medi-Cal insurance coverage kicks in. This monthly cost can be calculated by deducting the maintenance need of the household from the countable income. For instance, if an individual has a countable income of $1,800 after deductions and a maintenance need of $600, their shared monthly cost would be $1,200. This amount must be paid before Medi-Cal provides coverage for that month. It's important to note that the shared monthly cost only applies during months when medical coverage is needed, and there is no obligation to pay it during months without any health care expenses.
The cost structure of Medi-Cal also includes situations where an individual has both Medicare and Medi-Cal. In such cases, the copays from Medicare can be used to meet the shared monthly cost of Medi-Cal. Once the shared monthly cost is met, Medi-Cal will cover any remaining balance for that month. Additionally, supplemental health insurance policies can help reduce or eliminate the shared monthly cost by lowering countable income.
The costs associated with Medi-Cal have been a topic of discussion among California lawmakers. The state's expansion of Medi-Cal to cover undocumented immigrants has resulted in higher-than-expected enrollment numbers and increased costs. The annual cost of providing Medi-Cal coverage to undocumented immigrants is approximately $8.5 billion from the state's general fund. This has led to debates and concerns about the impact of rising Medicaid costs in California and other states.
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Frequently asked questions
Medi-Cal.
Medi-Cal is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Services (DHCS).
Medi-Cal covers 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 support.
As of April 2024, Medi-Cal covered nearly 15 million people, or about 40% of California's population.
Eligibility for Medi-Cal is based on income. Individuals with incomes up to 138% of the Federal Poverty Level (FPL) are eligible for Medi-Cal, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults.
