Medi-Cal

Lawful permanent residents (green card holders) are eligible for full-scope Medi-Cal in California regardless of their date of entry if they meet all other eligibility requirements, even if they have been in the United States for less than 5 years. Nonimmigrants and undocumented immigrants are not eligible for full-scope Medi-Cal, but if they meet all eligibility requirements other than immigration status, they can get restricted-scope Medi-Cal limited to emergency and pregnancy-related services.[11] Recently, Medi-cal has expanded full-scope benefits for individuals without immigration status. Young Adult Expansion or YAE now allows individual ages 19–26 full-scope benefits regardless of immigration status.[12] Older Adult Expansion or OAE now allows individuals 50 and over full-scope benefits regardless of immigration status.[13]

As of December 2022, 2.2 million people were enrolled in Medi-Cal fee-for-service, representing about 14.5% of all enrollees.[3] In the fee-for-service arrangement, health care providers submit claims to the Medi-Cal program for services rendered.[15]

Most beneficiaries receive Medi-Cal benefits from contracted Medicaid managed care organizations (MCOs). As of January 2018, 10.8 million people were enrolled in a Medi-Cal managed care plan, representing about 81% of all enrollees.[16]

California has several models of managed care which are designated at the county level:[17][18]

• 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, Imperial counties and the bi-county plan "CenCal Health" in San Luís Obispo and Santa Barbara.

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.[14] 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.[14] 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.[14] 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.[14]

In 2011, CMS approved a Section 1115 Medicaid waiver called Bridge to Reform. The program included an expansion of the patient-centered medical home primary care approach,[19] an expansion of coverage with the Low Income Health Program (LIHP), and incentive pay-for-performance to hospitals via the Delivery System Reform Incentive Pool (DSRIP).[20] It also made enrollment in managed care plans (as opposed to fee-for-service programs) mandatory for people with disabilities with the intention of improving care coordination and reducing costs.[21] The DSRIP program showed improvements in quality of care and population health, with less improvement in cost of care.[22]

Renewal of the waiver in 2015 extended the program to 2020 in an initiative called Medi-Cal 2020,[23] with additional programs including additional alternative payment systems, the Dental Transformation Initiative, and the Whole Person Care program focused on high-risk, high-utilizing recipients.[24] In the negotiation with CMS, several proposals were dropped.[25]

Medi-Cal enforces requirements on MCOs with contracts, with boilerplate versions posted online;[26] these contracts the primary way that the state affects the operations, quality, and coverage of managed care plans.[27] In 2005, the California Health Care Foundation recommend various steps to improve the plans, which resulted in some changes to the contracts.[27]

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.[28][29] C4Yourself and CalWIN are statewide online application systems that allows you to apply for benefits.[30][31]

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 related California 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 CFR 430 et seq.); while California's 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).[33]

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.[34] 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.[35]

Covered California is the health insurance marketplace in California, the state's implementation of the American Health Benefit Exchange provisions of the Patient Protection and Affordable Care Act.

Since 1933, California law has required counties to provide relief to the poor, including health care services and general assistance.[36] County indigent medical programs can be categorized as California Medical Service Program (CMSP) and Medically Indigent Service Program (MISP) counties.[37] 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.[38]