The purpose of Medi-Cal coverage is to provide healthcare services to beneficiaries who have low incomes. It can include families, seniors, people with disabilities, and children in foster care.

To meet the health needs of beneficiaries, California has moved away from a fee-for-service (FFS) payment, and delivery system to a risk-based managed care program.

Eligibility

Eligibility for Medi-Cal is determined by a person’s income and health status. The program covers more than 14 million California residents. People eligible for Medi-Cal coverage get comprehensive health benefits, including inpatient and outpatient care, prescription drugs, dental, vision, extended stays in skilled nursing facilities, and long-term care in nursing homes.

In addition, Medi-Cal also covers pregnancy and childbirth, including postpartum care. Pregnant women and new mothers are automatically enrolled in Medi-Cal if they meet the income requirements.

When you apply for Medi-Cal, it’s essential to have the following items on hand: Federal tax information (the head of your household and all their dependents must provide this) and proof of income.

Once you have completed your application, you will receive a determination letter. It will tell you if any household members qualify for Medi-Cal coverage and the amount you may pay in monthly premiums, copays, and deductibles.

Coverage

Medi-Cal is the primary source of health coverage for low-income children, adults, and people with disabilities in California.

To receive Medi-Cal, you must be a resident of a covered California county. These criteria are based on income, health status, and combinations. You can apply for Medi-Cal online or at your local county social services agency. You can also get help from a benefits planner or Medi-Cal eligibility worker.

Most beneficiaries are enrolled in Medi-Cal managed care plans, which deliver benefits through contracts with health plans that are accountable for and at financial risk for providing the services in their contract. Managed care allows the state to use data and performance measurements to monitor and ensure that health plans meet their obligations. The contracts can include performance measurement and monitoring tools, quality-related reports, and other accountability measures.

Most of the largest Medi-Cal enrollees are children, parents, and adults under age 65 who gained Medi-Cal eligibility under the ACA. The other major groups are seniors and people with disabilities.

Copays and Deductibles

Medi-Cal is a public health program that provides coverage for people with limited incomes. It includes adults, children, pregnant women, people with disabilities, and low-income seniors. It also covers urgent care services when needed by individuals in emergencies.

Most Medi-Cal recipients pay a fixed monthly amount for medical services, known as their share of the cost. The amount is calculated by dividing the individual’s net monthly non-exempt income by a maintenance need standard. Typically, this amount is less than the 138% federal poverty level.

In addition to their monthly cost share, Medi-Cal beneficiaries must meet deductibles and coinsurance. These two components of a Medi-Cal plan can sometimes apply toward the same medical service.

A deductible is a set amount you must pay for healthcare services before your insurance company begins covering them. It is typically a lower amount than a coinsurance, the percentage you must pay after the deductible is met.

As a result, patients are often surprised to see that they are paying more out of pocket for their coinsurance than they would be for their deductible. It can be especially true when you have an emergency and must pay a large sum out of pocket.

However, there are a few things to consider when it comes to copayments and deductibles:

First, you need to know that a copay does not count toward meeting your deductible. In other words, you don’t have to pay a copay for an exam before you’ve reached your deductible.

Depending on your type of health plan, your copay may not even be applied to your deductible. Several plans only require a copay once you reach your deductible, but others may charge them right away.

Requirements

When you are applying for Medi-Cal, you must meet specific requirements. These requirements are designed to ensure that the people who qualify for health care services get them. They include income and assets limits, a lookback period, and conditions for Medicaid expansion groups.

The requirements are necessary because they affect your eligibility and how much you will pay for health insurance. You must meet these requirements to get Medi-Cal coverage, and your family may retain the government subsidies that help cover the cost of your private plan.

In the past, Medicaid was a fee-for-service (FFS) system where beneficiaries could see any provider and were reimbursed for each visit or service. A managed care model is replacing this system. Health plans are contracted with the state to provide health benefits for enrollees in exchange for a monthly premium or capitation payment.

This transition has been challenging for Medicaid plans because of data issues. In the past, inaccurate enrollee contact information made it difficult for plans to connect beneficiaries with care coordinators and provide timely information on their medical needs. The state has improved its data-sharing processes, but contacting incoming enrollees and offering them care coordination services is still challenging.

Another challenge for Medicaid plans is the requirement that they provide health assessments to all enrolled beneficiaries, which can be difficult for those who do not have stable addresses. In addition, it can lead to delays in contacting enrollees and the need for more staffing.

The state has been trying to ease these challenges by removing some previously imposed restrictions on Medicaid-managed care. It also has been experimenting with different ways to reward and incentivize managed care.