Medi-Cal 101

Article
Jun. 14, 2021Updated Oct. 31, 2022

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 benefits, also check out our handy guide Making the Most of Medi-Cal.

What Services Does Medi-Cal Provide?

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

Who Is Eligible for Medi-Cal?

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 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.

Medi-Cal waiver eligibility infographic

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.

Types of Medi-Cal

Medi-Cal as a Primary Provider: Managed Care

  • In the absence of a private primary insurer, most children 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.
  • For families whose primary insurance is an HMO that is also offered by Medi-Cal, it may sometimes be permissible to enroll in the same Medi-Cal HMO, if available, for simplicity’s sake. Medi-Cal typically covers what the primary insurance doesn’t.

Medi-Cal as a Secondary Provider: Fee-for-Service (“Straight”) Medi-Cal

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

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.

Do you have more questions about how your child can benefit from Medi-Cal? Be sure to read our breakdown in Making the Most of Medi-Cal. You may also wish to read How Do We Pay For It All? Undivided’s Guide to Funding Resources.
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Contents


Overview

What Services Does Medi-Cal Provide?

Who Is Eligible for Medi-Cal?

Types of Medi-Cal

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