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]
Medi-Cal provides health coverage for people with low income and limited ability to pay for health coverage, including the aged, blind, disabled, young adults and children, pregnant women, persons in a skilled nursing or intermediate care home, and persons in the Breast and Cervical Cancer Treatment Program (BCCTP). [5] [6] [7] People receiving federally funded cash assistance programs, such as CalWORKs (a state implementation of the federal Temporary Assistance for Needy Families (TANF) program), the State Supplementation Program (SSP) (a state supplement to the federal Supplemental Security Income (SSI) program), foster care, adoption assistance, certain refugee assistance programs, or In-Home Supportive Services (IHSS) are also eligible. [5] [7]
As a means-tested program, Medi-Cal imposes asset limits on certain prospective enrollees. Medi-Cal individuals who receive long-term supportive services or who enroll in Medi-Cal through certain disabilities are subject to asset tests. This limit depends on the number of individuals being considered for coverage; for one enrollee, this limit is $2,000, while for two enrollees, the limit is $3,000. [8] Each additional individual being considered results in an additional $150 of permitted assets, up to a total of ten individuals covered. If applicants possess property whose total value exceeds the allowed amount, they are required to reduce ("sell down") their assets through activities such as purchasing clothes, purchasing home furnishings, paying medical bills, paying a home mortgage, paying home loans, and paying off other debts. [8]
Beginning in 2014 under the Patient Protection and Affordable Care Act (PPACA), those with family incomes up to 138% of the federal poverty level became eligible for Medi-Cal (pursuant to 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII)), and individuals with higher incomes and some small businesses may choose a plan in Covered California, California's health insurance marketplace, with potential government subsidies. [9] [10] Medi-Cal has open enrollment year-round.
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. Beginning in 2024, people without a lawful immigration status who meet the requirements for Medi-Cal are eligible for full-scope Medi-Cal. [11] Previously, meeting eligibility requirements other than immigration status qualified them restricted-scope Medi-Cal limited to emergency and pregnancy-related services only [12] unless they qualified for the Young Adult Expansion (YAE) or Older Adult Expansion (OAE), which allowed individuals ages 19–26 or those over the age of 50 full-scope benefits regardless of immigration status. [13] [14]
There are multiple ways to apply for Medi-Cal: one can apply at a Social Services office or over the phone by calling your nearest social service office, or one can apply online (the most common). Most websites make the application process clear and cohesive. They also allow for the user to select different languages to best navigate the website.
However, individuals in need of Medi-Cal often need help with their use of the online application process and face barriers, including [15]
Online applications seem to pose difficulty for those who aren’t tech-savvy. However, people can apply in-person or over the phone to avoid such confusion [16] .
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.
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]
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]
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. [17] 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. [17] 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. [17] 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. [17]
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, [21] 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). [22] 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. [23] The DSRIP program showed improvements in quality of care and population health, with less improvement in cost of care. [24]
Renewal of the waiver in 2015 extended the program to 2020 in an initiative called Medi-Cal 2020, [25] 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. [26] In the negotiation with CMS, several proposals were dropped. [27]
Medi-Cal enforces requirements on MCOs with contracts, with boilerplate versions posted online; [28] these contracts the primary way that the state affects the operations, quality, and coverage of managed care plans. [29] In 2005, the California Health Care Foundation recommend various steps to improve the plans, which resulted in some changes to the contracts. [29]
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. [30] [31] C4Yourself and CalWIN are statewide online application systems that allows you to apply for benefits. [32] [33]
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). [35]
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]
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. [38] County indigent medical programs can be categorized as California Medical Service Program (CMSP) and Medically Indigent Service Program (MISP) counties. [39] 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. [40]
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]
In the United States, Medicaid is a government program that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by state governments, which also have wide latitude in determining eligibility and benefits, but the federal government sets baseline standards for state Medicaid programs and provides a significant portion of their funding.
Medicare is a federal health insurance program in the United States for people age 65 or older and younger people with disabilities, including those with end stage renal disease and amyotrophic lateral sclerosis. It was begun in 1965 under the Social Security Administration and is now administered by the Centers for Medicare and Medicaid Services (CMS).
Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.
Medicare Part D, also called the Medicare prescription drug benefit, is an optional United States federal-government program to help Medicare beneficiaries pay for self-administered prescription drugs. Part D was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006. Under the program, drug benefits are provided by private insurance plans that receive premiums from both enrollees and the government. Part D plans typically pay most of the cost for prescriptions filled by their enrollees. However, plans are later reimbursed for much of this cost through rebates paid by manufacturers and pharmacies.
Program of All-inclusive Care for the Elderly (PACE) are programs within the United States that provide comprehensive health services for individuals age 55 and over who are sufficiently frail to be categorized as "nursing home eligible" by their state's Medicaid program. The ultimate goal of PACE programs is to keep eligible older adults out of nursing homes and within their communities for as long as possible. Services include primary and specialty medical care, nursing, nutrition, social services, therapies, pharmaceuticals, day health center services, home care, health-related transportation, minor modification to the home to accommodate disabilities, and anything else the program determines is medically necessary to maximize a member's health. If you or a loved one are eligible for nursing home level care but prefer to continue living at home, a PACE program can provide expansive health care and social opportunities during the day while you retain the comfort and familiarity of your home outside of day hours.
The Medicare Part D coverage gap was a period of consumer payments for prescription medication costs that lay between the initial coverage limit and the catastrophic coverage threshold when the consumer was a member of a Medicare Part D prescription-drug program administered by the United States federal government. The gap was reached after a shared insurer payment - consumer payment for all covered prescription drugs reached a government-set amount, and was left only after the consumer had paid full, unshared costs of an additional amount for the same prescriptions. Upon entering the gap, the prescription payments to date were re-set to $0 and continued until the maximum amount of the gap was reached or the then current annual period lapses. In calculating whether the maximum amount of gap had been reached, the "True-out-of-pocket" costs (TrOOP) were added together.
Medicare Advantage is a type of health plan offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs. The sponsors vary from primarily integrated health delivery systems to unions to other types of non profit charities to insurance companies. The largest sponsor is a hybrid: the non profit charity AARP using UnitedHealth.
Healthy San Francisco is a health access program launched in 2007 to subsidize medical care for uninsured residents of San Francisco, California. The program's stated objective is to bring universal health care to the city. Healthy San Francisco is not a true insurance program, as it does not cover services such as dental and vision care, and only covers services received in the city and county of San Francisco. The program itself acknowledges its limitations, and has stated that "insurance is always a better choice." Healthy San Francisco represents the first time a local government has attempted to provide health insurance for all of its constituents. The program is open to low-income city residents over the age of 18 who do not qualify for other public coverage, and who have had no insurance for at least 90 days. Eligibility is not conditional on citizenship, immigration, employment or health status. The program covers a range of services, but only pays providers within San Francisco. By July 2010, almost 90% of the uninsured adults in San Francisco — over 50,000 people — had enrolled in Healthy San Francisco.
Medicaid estate recovery is a required process under United States federal law in which state governments adjust (settle) or recover the cost of care and services from the estates of those who received Medicaid benefits after they die. By law, states may not settle any payments until after the beneficiary's death. States are required to adjust or recover all costs under certain circumstances, all involving long-term care arrangements. Federal law also gives states the option to adjust or recover the costs of all payments to health care providers except Medicare cost-sharing for anyone on Medicaid over the age of 55.
Medicaid managed care Medicaid and additional services in the United States through an arrangement between a state Medicaid agency and managed care organizations (MCOs) that accept a set payment – "capitation" – for these services. As of 2014, 26 states have contracts with MCOs to deliver long-term care for the elderly and individuals with disabilities. There are two main forms of Medicaid managed care, "risk-based MCOs" and "primary care case management (PCCM)."
The Local Initiative Health Authority for Los Angeles County is a public agency that provides health insurance for low-income individuals in Los Angeles County through four health coverage programs including Medi-Cal.
The California Department of Health Care Services (DHCS) is a department within the California Health and Human Services Agency that finances and administers a number of individual health care service delivery programs, including Medi-Cal, which provides health care services to low-income people. It was formerly known as the California Department of Health Services, which was reorganized in 2007 into the DHCS and the California Department of Public Health. On September 10, 2019, DHCS Director Jennifer Kent announced her resignation, effective September 30, 2019. On September 25, 2019, Governor Gavin Newsom appointed Richard Figueroa, Jr. as Acting Director. Will Lightbourne was appointed by Governor Gavin Newsom and began serving as Director on June 16, 2020. Subsequently, Michelle Baass was appointed Director of DHCS by Governor Gavin Newsom on September 10, 2021, replacing the outgoing Will Lightbourne.
Primary Care Case Management (PCCM), is a program of the United States government healthcare service Medicaid. It oversees the United States system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. In the mid-1980s, states began enrolling beneficiaries in their PCCM programs in an attempt to increase access and reduce inappropriate emergency department and other high cost care. Use increased steadily through the 1990s.
The California Children's Services (CCS) Program, established in 1927, is a partnership between state and counties that provides medical case management for children in California diagnosed with serious chronic diseases. It provides services to more than 165,000 children in California.
Welfare in California consists of federal welfare programs—which are often at least partially administered by state and county agencies—and several independent programs, which are usually administered by counties.
Covered California is the health insurance marketplace in the U.S. state of California established under the federal Patient Protection and Affordable Care Act (ACA). The exchange enables eligible individuals and small businesses to purchase private health insurance coverage at federally subsidized rates. It is administered by an independent agency of the government of California.
Healthy Way LA (HWLA) was a free public health care program available to underinsured or uninsured, low-income residents of Los Angeles County. The program, administered by the Los Angeles County Department of Health Services, was a Low Income Health Program (LIHP) approved under the 1115 Waiver. HWLA helped to narrow the large gap in access to health care among low-income populations by extending health care insurance to uninsured LA County residents living at 0 percent to 133 percent of the Federal Poverty Level (FPL). Individuals eligible for HWLA were assigned to a medical home within the LA County Department of Health Services (LADHS) or its partners, thus gaining access to continuous primary care, preventive and specialty services, mental health services, and other support systems. HWLA was one of the few sources of coordinated health care for disadvantaged adults without dependents in LA County. HWLA was succeeded by My Health LA, a no-cost health care program for low-income Los Angeles County residents launched on October 1, 2014.
The Affordable Care Act (ACA) is divided into 10 titles and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020. Below are some of the key provisions of the ACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.
This article summarizes healthcare in California.
Partnership HealthPlan of California, is an independent, public/private organization serving over 950,000 Medi-Cal beneficiaries in 24 northern California counties: Butte County, Colusa County, Del Norte County, Humboldt County, Glenn County, Lake County, Lassen County, Marin County, Mendocino County, Modoc County, Napa County, Nevada County, Placer County, Plumas County, Shasta County, Sierra County, Siskiyou County, Solano County, Sonoma County, Sutter County, Tehama County, Trinity County, Yolo County, Yuba County. It began operations as a County Organized Health System in 1994, and is currently the largest Medi-Cal Managed Care Plan in Northern California.
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