Medi-Cal
Medi-Cal is California’s Medicaid program and is the main source of health insurance for more than six million Californians, including a third of the state’s children. The program is administered at the state level by the Department of Health Care Services and at the county level by county Health and Social Services departments.
Medi-Cal covers children younger than 18, some adults age 18 to 21, parents of minor children, pregnant women, low income people who are 65 years of age and older, and some adults with disabilities. Eligibility for Medi-Cal also depends on an applicant’s income, assets, citizenship/immigration status, and living arrangements. Many people receive Medi-Cal services at no cost to themselves, but some people do have to pay a share of cost that they must pay before Medi-Cal provides coverage in any month.
Medi-Cal provides a variety of services including hospital services, physician visits, lab tests and x-rays, nursing home care, home health services, prescription drugs, vision services, dental care (through Denti-Cal), hospice, physical therapy and other services for adults determined to be “reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”
For children, Medi-Cal must cover any “necessary health care, diagnostic services, treatment and other measures… to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, where or not such services are covered under the State plan.”
Medi-Cal operates under two models, managed care and fee-for-service. Medi-Cal managed care beneficiaries are part of a health maintenance organization, or health plan, that is responsible for providing the beneficiary a primary care physician and approving procedures and specialists. Managed care is not available in all California counties. Some counties offer only one plan and others offer a variety of plans for beneficiaries to choose from. In addition, managed care is mandatory in certain counties through a County Organized Health System. The “fee for service” model is a system by which providers are reimbursed for each approved service they provide. Recipients are responsible for finding their own primary care physician and specialists that accept Medi-Cal fee for service.
Beneficiaries who are qualified for Medi-Cal also have dental coverage, known as Denti-Cal, provided either as fee for service or through a dental managed care plan. Medi-Cal mental health services are provided through the counties, even when the beneficiary receives other services through a managed care plan. Each county determines how Medi-Cal beneficiaries can access mental health services and establishes a network of providers.
Helpful Medi-Cal Resources:
Department of Health Care Services: