Wide Range of Health Benefits Provided by Medi-Cal

A comprehensive health insurance plan covers all medical expenses, including hospitalization due to severe illness. It also reimburses annual health check-ups and maternity costs, including normal and cesarean delivery. Millions of people in California use Medi-Cal, the state’s version of Medicaid. The program offers free or inexpensive medical treatment for kids, older people, and those with impairments.

Preventive Services

The Affordable Care Act requires that most private non-grandfathered plans provide a wide range of preventive services without imposing patient cost-sharing such as copayments or deductibles when provided by in-network providers. It includes Medicare Advantage and Part D plans. Additionally, it applies to state-run marketplace plans for kids’ health insurance and Medicaid programs in states that extend Medicaid to low-income adults and kids. Preventive services include screenings, vaccinations and counseling to help identify and manage medical problems before they become serious. These services can lower health care costs and save lives by identifying illnesses and diseases earlier, helping to manage those conditions better and preventing them from becoming more serious. The federal government has established a standard set of recommendations that qualify as preventive services for which you pay nothing (zero cost-sharing). It also applies to some special populations, such as transgender individuals. You can check from online websites like iehp.org to see if you’re eligible.

Emergency Services

Medi-Cal provides access to emergency services through a large network of providers. It includes hospitals, doctors and other healthcare providers. Medi-Cal also covers most of the cost of medications, including up to a 100-day supply of some drugs and most of the costs of various advanced diagnostic imaging procedures. Hospitals must serve patients with acute medical conditions under the Medical Treatment and Labor Act (EMTALA), regardless of their capacity to pay. To qualify for coverage under this law, a doctor must determine that the individual has an emergency medical condition.

The ACA (a federal healthcare reform act) required that all comprehensive health insurance plans in the individual and small group markets cover ten “essential” health benefits starting January 2014. These include medical, dental, mental health, prescription drug and vision (eye) care, medications your doctor prescribes, and transportation to and from your appointments for these services. Medi-Cal and Covered California, the state’s health exchange where Californians can shop for health insurance plans, must meet ACA requirements.

Medically Necessary Drugs

Medi-Cal can help pay for certain drugs that are medically necessary and required to treat your illness or condition. It includes medications for chronic diseases such as asthma, diabetes, tuberculosis, and cancer, as well as medications to help you sleep and relieve pain. The drug benefit provides a statewide system to manage utilization management protocols and enables DHCS to negotiate state supplemental drug rebates with pharmaceutical manufacturers. Additionally, the help offers a consistent approach for pharmacies and pharmacist prescribers to submit prior authorizations (PAs) that can be adjudicated in real-time and is designed to provide consistency across the entire Medi-Cal pharmacy benefit.

A new, external-facing internet website was launched in June 2020 to support communication and tools for the Medi-Cal Rx program. The site includes educational content and is updated frequently to communicate available resources, information, and changes for interested parties. A new Medi-Cal Rx Pharmacy Locator tool is also available to support the transition to Medi-Cal Rx. In addition, a direct, one-stop customer service call center was implemented for individuals who need assistance.

Preventive Care for Children

Physicians recommend that children receive well-child visits and several immunizations to help them stay healthy and avoid long-term health problems. If you qualify, Medi-Cal can pay for doctors’ visits, medications, dental screenings and more – depending on your county. Some counties offer managed care plans, which work much like HMOs. Other counties provide “Fee-for-Service” Medicaid. If you choose a Managed Care plan, you must use doctors and facilities in your plan’s network. 

Preventive Care for Adults

Getting recommended preventive services reduces your risk for disease, disability, and death. Millions of adults don’t get them, and the Affordable Care Act is helping change that.

The law eliminates cost-sharing for the preventive health screenings that most doctors recommend, such as Pap tests, mammograms, cholesterol screenings, HIV testing, STI screenings, and flu shots. It also requires Medicare to cover annual wellness visits with a personalized prevention plan. Most Medi-Cal members are enrolled in private health plans, called managed care plans, administered by county social services departments. Some counties offer one program for all their enrollees; others have multiple programs, each offering different options.

In most cases, the managed care plan you choose determines what type of doctor you can see and how often you can visit that doctor. Your plan can also decide which medications you can receive and what types of screenings and exams you must get. The 58 county human services departments are responsible for making eligibility decisions, overseeing managed care plan operations, and determining whether an individual has a resource limit that may impact their benefits.