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Medi Cal Explained

 MAGI Medi Cal  based on income below
138% of Federal Poverty Level

 

Earning too much for Medi-Cal??? Get Covered CA Quote here

Medi Cal Qualification under MAGI Income 

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What’s on this page?

#My Medi-Cal 
How to get the Health Care
You Need
24 pages

Smart Phones - try turning sideways to view pdf better
My medi cal explanation of medi cal

Instant Term Life Insurance Quotes

Eligibility 

Undocumented,  Illegal, Lawful Presence

dhcs medi cal immigrant eligibility faq

DHCS.gov   Medi Cal Immigrant FAQ on Eligibility

 

Medi Cal Contact Information

 

 

  • Ombudsman Webpage
    • Phone: 1-888-452-8609
    • Email:   [email protected] 
      • The Office of Ombudsman cannot approve/terminate/reinstate Medi-Cal eligibility; alter aid codes, change/update addresses, change/update name or initiate inter-county transfers.

See our Main Webpage on Medi Cal contact information

Non MAGI Medi Cal

Child & Sibling Pages
Site Map 

[sibling-pages]

 

Benefits

Medical

Dental

#Denti Cal Beneficiary Handbook 2023  

denti cal handbook

Medi Cal Vision Coverage

 

Trump Big Beautiful Bill Changes

 

  • Need Medicaid? Then Get a Job
  • The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.
  • In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.
  • The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.
  • Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF, a health information nonprofit that includes KFF Health News.
  • State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.
  • “The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.      Kff News *
  • ICE is gaining access to trove of Medicaid records, adding new peril for immigrants  
  • Texing???  

 

Medi Cal to Covered CA Fact Sheet 

medi cal to covered ca

 

  • Unpacking the Unwinding: Medicaid to Marketplace Coverage Transitions  Georgetown University 9/18/2024
  • Medi-Cal to Covered California Enrollment Program Toolkit  Covered CA 10/15/2024
  • AI  Summary
  • To move from Medi-Cal to Covered California, you must report the income change to your local county Medi-Cal office within 10 days because they manage Medi-Cal eligibility. After the county office updates your income and your Medi-Cal case is closed, they will often update your Covered California account for you, which may allow you to enroll in a new plan with a premium subsidy. 
     
    Step 1: Report the change to your local county Medi-Cal office 
    • Contact your county social services or Medi-Cal office immediately. You can find a list of county offices on the DHCS website.
    • You can report changes online through BenefitsCal.com or by calling your county office.
    • Be prepared to provide proof of the income change, such as recent pay stubs or tax returns.
    • Report this change within 10 days of the income increase. 
     
    Step 2: Wait for the county to update your case 
    • The county office will process the change and determine if your income makes you ineligible for Medi-Cal.
    • If you are found ineligible for Medi-Cal, the county office will close your case. 
     
    Step 3: Confirm your Covered California account is updated 
    • Once your Medi-Cal case is closed, the county eligibility worker will often update the income information in your Covered California account to help facilitate your transition to a new plan.
    • Check your Covered California account to see if your eligibility for subsidies has changed.
    • If you have questions or don’t see the changes reflected in your account, call the Covered California Service Center at (800) 300-1506 for assistance. 
  • Resources & Links

 

Medi-Cal Managed Care HMO – Health Care Options 

#Pick your Plan

Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.

Medi Cal Provider HMO Selection Website

learn choose enroll medi cal plans

Medi Cal  HMO #Providers

Learn more:

While you can have an employer or Indivudaul Plan and Medi Cal, there is However  a
#MANDATORY Medi Cal Managed Care – HMO health
Enrollment

One  must choose a  Managed Care – HMO health plan – provider within 30 days after enrollment in Medi-Cal otherwise the State will pick plan for you. Medi-Cal Website  Unless you have Other Health Coverage -OHC, then you must go Fee for Service.

When you have an HMO  managed health care, the State of California makes a deal  with health plans and pays a fixed amount each month per member enrolled in the plan – capitation.   The HMO health plan is then responsible for providing you  all your Medi-Cal services included under the EOC Evidence of Coverage.   HMO Plans are required under state and federal law to maintain an adequate Medi-Cal provider network to ensure that each member has a primary care physician and must report on quality and access measures.

#Clarification from Medi-Cal on
HMO Mandatory Enrollment and other coverage OHC

Hi Steve –
 
On May 8, you reached out to our Office of Communications, and requested answers to the following questions.  Please see DHCS’ responses*** below.
 
  1. What are the Medi Cal HMO’s doing to stop those with other coverage from enrolling?
  1. On this DHCS page, the public is told they must choose an HMO.  Nothing is said about if you have other coverage, it’s excluded. [not mentioned on the DHCS page?]
 
Medi-Cal managed care plans do not stop beneficiaries from enrolling in private health insurance plans.  If a Medi-Cal beneficiary is currently enrolled in a Medi-Cal managed care plan, and subsequently purchases private health insurance, they will not be disenrolled from the Medi-Cal managed care plan. 
 

The website above only applies to Medi-Cal beneficiaries who are required to enroll in a Medi-Cal managed care plan, which is the large majority of the Medi-Cal population. 

 

 

 
 
  1. On or about 10.26.2020 the Medi Cal Ombudsman emailed and said that if one had private insurance they could NOT enroll in a Medi Cal Managed Care Plan!
 

If a Medi-Cal beneficiary has active other health coverage upon Medi-Cal enrollment, they are currently not eligible for enrollment into a managed care plan. 

 

 

 
However, Medi-Cal beneficiaries with other health insurance will be eligible to enroll in a managed care plan after DHCS implements the California Advancing and Innovating Medi-Cal (CalAIM) initiative to transition share of cost beneficiaries to Medi-Cal managed care for non-duals (Medi-Cal coverage only) on January 1, 2022 and duals (Medicare and Medi-Cal coverage) in January 1, 2023.
 
  1. When one has a Medi Cal HMO and other coverage – can the patient still pick which provider or plan to go to?
 
A Medi-Cal beneficiary who has other health insurance (OHC) is required to exhaust their OHC before Medi-Cal assumes payment for a service.  However, Medi-Cal providers are not allowed to deny a medically necessary service even if the provider has evidence that a beneficiary has OHC. In order for the provider to bill Medi-Cal for that service, the provider must first obtain a denial letter from the OHC entity.  (Other Health Coverage (OHC) Guidelines for Billing (other guide) (ca.gov) pg1)
 
  1. When a member uses HMO services, how does the HMO collect & bill other coverage?
 
Assuming that you are referring to “HMO” as a Medi-Cal managed care plan, the State has direct data exchanges with commercial health insurance carriers to identify members with other health coverage. This data is shared with Medi-Cal Managed Care Plans to ensure effective coordination of benefits. If other health coverage information is present at time of billing, the Medi-Cal managed care plan will reject (not deny) the claim and provide the other health coverage information to the provider for billing. If other health coverage information is obtained after a Medi-Cal managed care plan has paid for the claim, the plan will initiate post-payment recovery.
 
  1. When a member uses say his Employer’s HMO or PPO how does the  collect copays & deductibles  from Medi Cal HMO and/or fee for service?
 
Medi-Cal managed care plans and Medi-Cal fee-for-service do not pay for a Medi-Cal beneficiary’s copays or deductibles for their employer’s HMO/PPO plan. 
 

The DHCS Health Insurance Premium Payment program does offer an option for a narrow population of newly enrolled Medi-Cal beneficiaries to receive reimbursement for OHC co-pays and deductibles for a limited time, subject to eligibility requirements.  Please see dhcs.ca.gov for additional information.   

 

 

 

 
  1. Of the four approaches to Managed Care & Third Party Liability on Medicaid.Gov which
    is CA using?
  1. How is this being enforced & implemented?
 

                 CA currently uses the two out of four approaches:

 

 

 

 
·  Enrollees with any other insurance coverage are excluded from enrollment in managed care (note that this will change after Cal AIM implementation)
· Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the MCO with an appropriate adjustment of the MCO capitation payments
o This approach is used when a Medi-Cal beneficiary is first enrolled in a Medi-Cal managed care plan and subsequently obtains other health coverage. TPL responsibilities are then delegated to the Medi-Cal managed care plan for the first 12 months after the date of payment for a service.
 
If you have any additional questions on other health coverage and Medi-Cal, please let me know.
 
 
Thank you!
 
Lindsey Wilson, Chief
Coordination of Benefits and Administration
Third Party Liability and Recovery Division 
 
***Please note that a few things in the letter were changed, so that it would look better when posted on the web.
 
 
Contrast…
 

You cannot choose a medical HMO Managed Care plan if:

 

 

 

You are a member of a commercial medical plan through private insurance Health Care Options DHCA.Gov *  response from the Medi Cal Ombudsman * Western Poverty Law Page 5.219 * Medicaid.gov *

You must take Fee for Service.

Request for exemption from enrollment in Managed Care Plan, but I don’t see OHC as a reason

IEHP Provider manual seems to imply their HMO will allow it?

  • EHP .org/manuals Medi-Cal
  • 20 – Claims Processing (PDF)

See the email we rec’d May 17th from Medi Cal to clarify some of these issues

Cal AIM  Improvements?

Trump, whatever less coverage

FAQ’s

When does coverage #start?

 

Documentation Required during

Covered CA 90 Day  #Conditional Eligibility 

A 90 day conditional eligibility notice  means that you get coverage for 90 days even though Covered CA hasn’t verified that you qualify.  As long as you send the proofs that are being asked for, everything is fine!  There is NOTHING to worry about!  Just comply.  If you have trouble with compliance, email us.

Clients need to submit valid documentation for one or more of the following reasons:

You  can upload, fax, send to their Certified Agent or mail their documentation. More than one document may be required.

View our Conditional Eligibility Quick Guide * or Job Aid for more information on the notice and to view a list of acceptable Verification Documentation.

Look for this sentence in the letter that you get from Covered CA.

We need your proof within 90 days. If we get a response and you prove your citizenship by the due date above, you will keep your insurance through Covered California.

Here’s the biggest lesson I learned in one year of law school.  Read everything 3 times and when you think you understand it, read it again.

conditional eligibilty

Resources & Links

Medi Cal
out of state and  #emergency coverage?

 

  • CA Medi Cal – Out-of-state medical care is limited to the following:
    • (a) (1) When an emergency arises from accident, injury or illness; or
    • (2) Where the health of the individual would be endangered if care and services are postponed until it is feasible that he/she return to California; or
    • (3) Where the health of the individual would be endangered if he/she undertook travel to return to California; or
    • (4) When it is customary practice in border communities for residents to use medical resources in adjacent areas outside the State; or
    • (5) When an out-of-state treatment plan has been proposed by the beneficiary’s attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.
  • (6) Prior authorization is required for all out-of-state services, except:
    • (A) Emergency services as defined in §51056.
      • “emergency services” means those services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to disability or death.
    • (B) Services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services.  texas.gov/medicaid
    • Medi Cal Treatment Authorization Request
      • 540-1 (a) (5) When an out-of-state treatment plan has been proposed by the beneficiary’s attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State
  • Medi Cal only covers outside of CA for emergencies and very special circumstances.  Cornel Law *
  • Sources

#Explanation from Western Poverty Law

western poverty law advocate guide

table of contents western poverty law

Much more #detail on Medi Cal

 

Medi-Cal determines eligibility based on #monthly, not annual income. 

  • Even you you make $100k per year, but have a month with no income, you would qualify.  This can even get you around the Open and Special Enrollment restrictions.  That is, if you have a bad month, enroll, then when you get kicked out of Medi-Cal for making too much money, as you reported it, as required by law, within 10 days, thank G-d, you have a special enrollment into Covered CA or direct with an Insurance Company.  No extra charge for us to help you enroll in Covered CA!  Insure Me Kevin.com *  Western Poverty Law *  DHCS ACWDLS * 2015 Medi-Cal Eligibility Division Information Letters (MEDILs) * 15-03 * 
  • Plain English from Covered CA Broker Department Email
  • In regards to Medi-cal,  they review monthly income.
  • So if a client has been making $2000 a month and they do a report a change and it goes now to $1000 a month for 1 person, they will now be eligible for medi-cal.
  • If the income goes back up to $2000 a month, they contact [report a change] Medi-cal and they are dis-enrolled from medi-cal and now are eligible for Covered CA. Response By Email (Argelia) (09/08/2016 11:56 AM)

 

 

Report Changes Promptly 

MORE

Much more on Medi Cal

 

 

******************************************

Western Poverty Law - Insurance for Low Income

Advocate Guide to Medi Cal 

advocate guide to Medi Cal

Nolo Social Security, Medicare, Medi Cal & Government Pensions

nolo social security government pensions

 

  • Our Webpage on COVID 19

  • CA State Senator Steven Bradford 35th District 
  • His Webpage on COVID 19 Resources

  • BIC Benefits Identification Card

    Sample BIC Card

  • How to replace lost or stolen card?

Ask us a Question? FAQ's?

FAQ’s “C-CHIP County Children’s Health Initiative Program”

FAQ’s

  • How does Covered California work with Medi-Cal?
    • Covered California will act as a “one-stop shop” for health insurance. Through Covered California, you will be able to apply for Medi-Cal benefits electronically and receive a real-time eligibility results. You will also be able to report changes online and receive real-time customer support 24 hours a day. dhcs.gov More FAQ’s DHCS ♦ Insure Me Kevin.com
    • Disability Benefits 101 – Medi-Cal The Details
  • What is ​California Advancing and​ Innovating Medi-Cal (CalAIM)
    • Cal Aim is a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated​, and person-centered approach to maximizing their health and life trajectory.​​​​
    • Goals of C​alAIM​
      • 1. Identify and manage comprehensive needs through whole person care approaches and social drivers of health.
      • 2. Improve quality outcomes, reduce health disparities, and transform the delivery system through value‑based initiatives, modernization, and payment reform.
      • 3. Make Medi-Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility. DHCS *
  • why doesn’t medi-cal really help? So long on #hold, so much wasted time?

Effective Date? Temporary Instant ID Card”

 

Medi Cal & Seniors

 

  • Medi-Cal is California’s Medicaid program, which provides health insurance to individuals and families who earn low incomes, including 40% of the state’s children, half of Californians with disabilities, and over a million seniors. In total, the program covers more than 12 million people, or nearly one in three Californians.
  • Medi-Cal also covers a large number of working Californians, many of whom became eligible for the program because of the Affordable Care Act’s Medicaid expansion. Working Californians may be one of the least recognized or understood populations served by the program. In a 2018 poll, 42% of Californians said that they believed that most working-age adults without a disability enrolled in Medi-Cal are unemployed. Twenty percent said they didn’t know. This report combines key findings from survey data with insights from 19 in-depth interviews with enrollees to paint a more accurate and complete picture of working Californians who rely on Medi-Cal, why they came to enroll in the program, and the role it plays in their lives.
  •  
  • VIDEO 
  • Working Californians Enrolled in Medi-Cal Share Their Stories   
  • Chcf Policy at a Glance  

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