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, occupational, and speech therapy 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, or HCBS-DD waiver. 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.

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 existing or recent Kaiser members).

  • 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.

  • NOTE: Effective January 1, 2024, Kaiser Permanente will have its own contract with the state and will no longer be contracted under LA Care. Current Kaiser Medi-Cal patients should be transferred to the Kaiser state plan and should not need to take further action. New recipients will be permitted to select Kaiser Medi-Cal coverage if they are current Kaiser members, have been a Kaiser member in the past 12 months, or have a Kaiser member in their immediate family. Current and former foster youth and recipients eligible for both Medicare and Medi-Cal will also be able to choose Kaiser.

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 how to choose a managed care plan and communicate with your providers about your 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.

• If your child is not currently enrolled in Medi-Cal, you can create an account on BenefitsCal to start an application for your child.
• If your child is a Regional Center client, there are a few extra steps to enrolling via the HCBS-DD waiver, so be sure to see our article with instructions and tips.
• If your child is not a Regional Center client but does have complex medical needs, see this article for enrolling in Medi-Cal via the HCBA waiver.
• The Undivided app has step-by-step guides for applying for Medi-Cal benefits via each of these methods, so create an account if you haven’t already to get started.

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.

If you're looking for your local Medi-Cal office, you can find office listings by county on the DHCS website. For checking benefits status, most counties are using BenefitsCal.