Katana VentraIP

Medi-Cal

The California Medical Assistance Program (Medi-Cal or MediCal) is the California 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 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 support.[1] Medi-Cal was created in 1965 by the California Medical Assistance Program a few months after the national legislation was passed.[2] Approximately 15.28 million people were enrolled in Medi-Cal as of September 2022,[3] or about 40% of California's population; in most counties, more than half of eligible residents were enrolled as of 2020.[4]

Rejection of applications due to insufficient explanation

Repeated requests for additional documentation throughout the application process

Unclear next steps and transitions in the application process, both for applications submitted directly to Medi-Cal and those initiated through Covered California

Difficulty accessing support and personalized assistance, including in-language help and resources for Spanish- and Mandarin-speaking applicants

Challenges in navigating Medi-Cal eligibility and enrollment during significant life transitions, such as aging out of foster care, transitioning off a parent’s health insurance plan, giving birth, getting a divorce, or losing or gaining employer-sponsored insurance.

Sometimes, individuals don’t have access to the internet or experience confusion.

Benefits[edit]

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.[1] California is one of a few US states that provide Medicaid dental benefits to adults.[17]


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.

Administration[edit]

Medi-Cal fee for service[edit]

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.[18]

Medi-Cal managed care[edit]

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.[19]


California has several models of managed care which are designated at the county level:[20]

Related programs[edit]

Partnership for Long-Term Care[edit]

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.[36] 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.[37]

Quality of care metrics[edit]

Medi-Cal reports quality metrics, broadly similar to the HEDIS metrics from the NCQA.


In 2017, it reported on 13 of the 20 frequently reported from the CMS Medicaid/CHIP Child Core Set and 15 of 19 frequently reported from the CMS Medicaid Adult Core Set.[41]

Healthcare in California

Welfare in California

Local government in California

Health care districts in California

Official website

BenefitsCal.org

C4Yourself system

in the California Code of Regulations

California Medical Assistance Program

information for California

Medicaid State Plan

for Medicaid program in California

State Waivers