Medi-Cal 101

Medi-Cal is California’s Medicaid program, which provides health care coverage to many Californians based on a variety of factors including income, adoption/foster care status, and disability. Medi-Cal will always be secondary coverage for children with private primary insurance, but it can help fill some of the funding gaps by eliminating copays and many other out-of-pocket expenses when your child sees Medi-Cal-contracted providers. Medi-Cal may also fund medical supplies (such as diapers and feeding-tube formula) and durable medical equipment.

Medi-Cal for children is administered through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Some services that are not available to adults with Medi-Cal may be available under EPSDT.

To help you understand the various Medi-Cal programs and how your child might benefit, also check out our handy guide Making the Most of Medi-Cal and our glossary of Medi-Cal terms and services.

Common Medi-Cal services include (but are not limited to):

• Medical coverage

• Physical and occupational therapy and speech when medically necessary

• Applied Behavioral Analysis (ABA; managed care plans only)

• Equipment and supplies

• Incontinence supplies

• Home nursing care

• In-Home Supportive Services (IHSS)

Eligibility for Medi-Cal is usually based on household income. However, California offers several programs that allow people with disabilities to obtain Medi-Cal if their income is too high to qualify based solely on financial need. (These include, among others, the Medically Needy Share of Cost Program, the Aged and Disabled Federal Poverty Level program, and the 250% Working Disabled Program, which may be useful for young adults with disabilities whose monthly income is too high for the other programs.)

The program most often utilized by the families of children with developmental disabilities is the institutional deeming waiver for individuals with developmental disabilities. This program allows many children who are Regional Center clients to receive Medi-Cal without regard to family income. For children with private health coverage, Medi-Cal coverage will be considered secondary insurance, and may cover out-of-pocket expenses when you see a provider who accepts Medi-Cal.

Other programs include the Aged, Blind and Disabled - Medically Needy program (which requires a monthly Share of Cost), the Aged & Disabled Federal Poverty Level program, and the 250% Working Disabled program, which may be useful for young adults with disabilities whose monthly income is too high for the other programs.

Medi-Cal as a Primary Provider:

• Most children with Medi-Cal as primary coverage will be enrolled in a Medi-Cal managed care plan. For Los Angeles County, those managed care plans include HealthNet and LA Care or a contracted plan under LA Care, such as Anthem Blue Cross, Blue Shield of California Promise Health Plan, and, under limited circumstances, Kaiser Permanente (usually for past/recent Kaiser patients).

  • These plans operate like any other managed care plan. You will receive an enrollment packet and both a Benefits Identification Card (BIC) and a managed care health plan card, along with instructions for finding in-network providers. New Medi-Cal recipients are encouraged to call Health Care Options and select a plan. If they fail to do so, one will be chosen for them.

Medi-Cal as a Secondary Provider

If a child has multiple insurance plans, Medi-Cal is always the last provider to be billed. For most beneficiaries, this means Medi-Cal will be your secondary insurance. You can read all about using Medi-Cal as secondary health coverage in this article.

Until recently, families with secondary Medi-Cal coverage were exempt from enrolling in a Medi-Cal managed care plan. This changed effective January 1, 2023. See our article on the recent changes to Medi-Cal and how to choose a managed care plan for secondary coverage.

Treatment Authorization Requests (TARs)

Some services and medications require prior authorization by Medi-Cal. The provider will submit the TAR and check its status. If the TAR is denied and you disagree with the decision, you may be able to request a fair hearing or state hearing.