Who is covered under the Medi-Cal Program?

Californians are automatically eligible for Medi-Cal with no share of cost if they receive benefits from one of the following programs:

• SSI/SSP
• CalWorks (AFDC)
• Refugee Assistance
• Foster Care, or
• Adoption Assistance

 

Persons who meet particular income and resource requirements are potentially eligible for Medi-Cal benefits if they are:

• 65 or older
• Blind
• Disabled
• Under 21
• Pregnant
• In a skilled nursing or intermediate care home
• On refugee status for a limited time, depending how long you have been in the United States
• A parent or caretaker relative of a child under 21 if:
  • The child's parent is deceased or doesn't live with the child, or
  • The child's parent is incapacitated, or
  • The child's parent is under employed or unemployed
• Have been screened for breast and/or cervical cancer (Breast and Cervical Cancer Treatment Program)

Medi-Cal eligibility will be expanded effective January 1, 2014.

For more information, visit the California Department of Health Care Services Website: http://www.dhcs.ca.gov/dataandstats/statistics/Pages/RASB_Medi-Cal_Overview.aspx

Beginning January 1, 2014, single adults without children, ages 19-64 will be eligible for Medi-Cal in addition to those eligible under the previous requirements. Open enrollment for Medi-Cal coverage for these individuals begins on October 1, 2013. If they are found to be eligible, their coverage begins on January 1, 2014. For more information on Medi-Cal and the 2014 expansion, visit the California Department of Health Care Services website: http://www.dhcs.ca.gov/Pages/Medi-CalExpansionInformation.aspx

Medi-Cal offers a broad range of services. Some services are federally mandated, while the state has elected to offer optional services available under the Medicaid program. Medi-Cal services include, but are not limited to:

• Inpatient and Outpatient Hospital Care
• Physician and Clinic services
• Laboratory and X-ray Services
• Skilled Nursing Facility services
• Home Health Services
• Home and Community-Based Services
• Renal Dialysis Services
• Mental Health Services
• Dental Services
• Personal Care Services

The availability of services may be limited to certain eligible groups. All services rendered must meet certain requirements, including medical necessity and may require prior authorization. Credit - http://www.dhcs.ca.gov/dataandstats/statistics/Pages/RASB_Medi-Cal_Overview.aspx

Medi-Cal covers a core set of services, including doctor visits, hospital care, and pregnancy-related services, as well as nursing home care for individuals age 21 or older through either a fee-for-service or managed care delivery system. For a majority of enrollees, Medi-Cal provides covered services through managed health plans in all 58 counties. The ACA ensures all Medi-Cal health plans offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include:

 

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental Health and Substance Use Disorder Services including Behavioral Health Treatment
• Prescription Drugs
• Rehabilitative and Habilitative Services and devices
• Laboratory services
• Preventive and wellness services & chronic disease management
• Pediatric services (including oral and vision care)

 

Starting in 2014, the array of mental health and substance use disorder services will expand to better meet the needs of individuals eligible for Medi-Cal. The following mental health benefits will be available through Medi-Cal managed care plans or the fee-for-service delivery system:

 

• Individual and group mental health evaluation and treatment (psychotherapy)
• Psychological testing when clinically indicated to evaluate a mental health condition
• Outpatient services for the purposes of monitoring drug therapy
• Outpatient laboratory, drugs, supplies and supplements
• Psychiatric consultation
• Specialty mental health services currently provided by County Mental Health Plans will continue to be available.

 

The following substance use disorder service benefits will also be made available to eligible Medi-Cal beneficiaries:

 

• Voluntary Inpatient Detoxification
• Intensive Outpatient Treatment Services
• Residential Treatment Services
• Outpatient Drug Free Services
• Narcotic Treatment Services

 

Many of these services are covered by Medi-Cal today or will be added in 2014 and will be available for both current and new enrollees. Dental care, vision services and speech therapy are generally available only to children and youths under age 21, but certain adults and pregnant women are also eligible for these services. Dental services will be available to all adults starting May, 2014.

Dental care, vision services and speech therapy are generally available only to children and youths under age 21, but certain adults and pregnant women are also eligible for these services. Dental services will be available to all adults starting May, 2014.

For more information on dental services through Medi-Cal fee-for-service, please visit the Denti-Cal website at: http://www.denti-cal.ca.gov/. For more information on dental services in Sacramento or Los Angeles County through dental managed care plans, please visit the Denti-Cal website at: http://www.denti-cal.ca.gov/WSI/ManagedCare.jsp?fname=ManagedCarePlanDir.

The Medi-Cal program operates under two primary care delivery models: Fee-For-Service (FFS) Medi-Cal and Medi-Cal Managed Care. In the FFS Medi-Cal model, health care providers are reimbursed through a Medi-Cal Fiscal Intermediary. In the Medi-Cal Managed Care model, the California Department of Health Care Services contracts with health insurance organizations to provide services to groups of Medi-Cal eligibles in specific counties. Benefits paid under the Medi-Cal Managed Care plan vary by contract and any non-covered managed care services are paid through the FFS Medi-Cal delivery model. Specialty Medi-Cal programs such as Mental Health, Developmental Services and Personal Care Services are administered through other state departments.

Credit - http://www.dhcs.ca.gov/dataandstats/statistics/Pages/RASB_Medi-Cal_Overview.aspx