Medi-Cal (California’s Medicaid program) is the largest payer for health care services in the State, covering one-third, or 14 million, of the State’s residents. Of that number, nearly 80% (10.6 million) of Medi-Cal beneficiaries receive their care through a managed care delivery system. The California Department of Health Care Services (DHCS) is California’s Medicaid Agency.
Within the Medi-Cal managed care program, California currently uses a variety of different models to deliver care: County Organized Health Systems (COHS), Geographic Managed Care (GMC), Two-Plan Model, and Regional Model. Currently, a total of 24 plans contract with the Department of Health Care Services (DHCS) to provide Medi-Cal managed care services to beneficiaries. Of these, 16 are local health plans. The 16 LHPC member health plans participate in the Two-Plan, COHS and GMC models, covering over 70% (7.5 million) of all Medi-Cal beneficiaries.
Managed Care Requirements and Regulation
DHCS shares regulatory authority over the Medi-Cal health plans with the Department of Managed Health Care (DMHC) which is responsible for oversight of health plans subject to the Knox-Keene Act. Under the Knox-Keene Act, plans are required to follow requirements to ensure beneficiaries have access to health care, such as network adequacy standards, timely access requirements, appeal and grievance processes, timely payment of claims, and maintenance of adequate financial reserves.
Eligibility and Enrollment
California has multiple pathways for persons to become Medi-Cal beneficiaries. The two primary ways of determining Medi-Cal eligibility are through County Social Services Agencies (SSAs) and through the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) which is the single point of entry for health coverage required under the federal Affordable Care Act (ACA). Applications can be completed online, in person, or by mail. Numerous community-based organizations and healthcare providers around the state provide assistance in applying for Medi-Cal. County SSA staff process Medi-Cal applications and determine eligibility.
Once eligibility is determined, the beneficiary is enrolled into Medi-Cal and is issued a Benefits Identification Card (BIC). In COHS counties, all beneficiaries are mandatorily enrolled into the single COHS plan. In San Benito County where there is only one health plan available, beneficiaries may enroll in that plan or choose to receive Medi-Cal fee-for-service. In all other counties where there are at least two health plans, beneficiaries receive a choice packet from DHCS to use to select a plan. Any beneficiaries who do not select a plan are automatically assigned to one. Beneficiaries may change plans for any reason or if they move to another county by contacting DHCS’s Health Care Options (HCO) program by phone or by mail using an Enrollment Choice Form. Within DHCS, HCO manages the state’s enrollment broker which is responsible for helping Medi-Cal enrollees make informed choices regarding their health plan selection.
Once a beneficiary enrolls in a plan, the beneficiary chooses a primary care provider (PCP) who is either a doctor or clinic that is part of the health plan’s network. If no PCP is selected, one will be assigned. Beneficiaries may change PCPs at any time by calling the health plan’s member services department. Beneficiaries receive a provider directory, or can access the provider directory online, to see complete information about the providers who are contracted with the health plan, including address and telephone number, hours, available services and benefits, languages spoken, and after-hours phone number.
The Medi-Cal program offers a comprehensive set of health benefits at no cost to the beneficiary – there are no premiums or co-payments. Some Medi-Cal benefits are not included in the health plans’ contracts and are “carved-out” of managed care (i.e., administered by another entity other than the health plan). In general, these carve-out benefits include dental benefits, California Children’s Services, AIDS Drug Assistance Program, specialty mental health, Drug Medi-Cal, and In-Home Supportive Services (IHSS). In many instances, the carved-out benefits are administered by the State or county agencies.
Network Adequacy Standards
Network adequacy requirements are established under the Knox-Keene Act and further specified in regulation. In addition, DHCS places network adequacy standards on health plans operating as Medi-Cal managed care plans. The health plan contracts set forth the Medi-Cal specific network adequacy and access standards.
Medi-Cal managed care plans are required to provide a comprehensive range of primary, specialty, institutional, and ancillary services readily available at reasonable times to all beneficiaries. Primary care and hospital services must be available within 10 miles or 30 minutes of the beneficiary’s residence. Specialty care access standards are based on county population size. In large counties, specialty care must be available within 15 miles or 30 minutes of the beneficiary’s residence. Pharmacy services must be available within 10 miles or 30 minutes of the beneficiary’s residence.
Medi-Cal managed care plans are also required to continuously maintain networks that satisfy specific provider to beneficiary ratios (i.e., one PCP for every 2,000 beneficiaries; one full-time equivalent physician for every 1,200 beneficiaries; and one non-physician medical practitioner per 1,000 beneficiaries). Emergency services must be available 24 hours a day, seven days a week.
The full set of network adequacy standards can be found on DHCS’ website.
Timely Access Standards
Additionally, Medi-Cal managed care plans are required to meet timely access requirements for appointment wait times. Examples of the standards for timely appointments are:
48 hours for urgent care with no prior authorization;
10 business days from request for non-urgent primary care;
15 business days from request for specialist;
10 business days for first prenatal visit;
In addition to specific appointment wait-time standards, network providers must maintain procedures for triaging members’ telephone calls to provide telephonic medical advice and access to interpreters.
Managed care plans must also ensure that providers have a licensed professional to answer after-hours calls.
The full set of timely access standards care be found on DHCS’s website.
Medi-Cal beneficiaries enrolled in managed care plans have certain member rights that must be maintained and communicated to beneficiaries and providers. All beneficiaries receive a member services guide that includes information about covered benefits, accessing covered services, selecting and changing PCPs, availability and procedures for obtaining after-hours services, procedures for obtaining emergency health care, the process for referral to specialists, procedures for filing a grievance or appeal, the right to a Medi-Cal State Fair Hearing and process, and more.
Beneficiaries have the right to voice grievances, either verbally or in writing, about the health plan or the care they received. Beneficiaries can appeal health plan decisions regarding coverage and benefits. The beneficiary must exhaust the health plan appeals process before requesting a Medi-Cal State Fair Hearing.
Managed care plans are responsible for ensuring that appropriate processes are used to review and approve the provision of medically necessary covered services. The role of utilization management is to review requested services using specific criteria in order to approve, modify, defer, or deny services. The health plans work with the providers to communicate procedures and services that require prior authorization and the process for obtaining prior authorization for these services. Providers and beneficiaries are notified in writing regarding denied, deferred, or modified referrals; both providers and beneficiaries have the right to appeal these decisions.
Care Coordination and Case Management
Care coordination encompasses the services which are included in basic and complex case management, comprehensive medical case management services, person centered planning, and discharge planning. Managed care plans are responsible for providing appropriate case management to beneficiaries. The plan provides either basic or complex care management activities based on the medical needs of the beneficiary.
Basic case management services are provided by the PCP, in collaboration with the managed care plan, and include: initial health assessment (IHA); individual health education behavioral assessment (IHEBA); identification of appropriate providers and facilities to meet beneficiary care needs; direct communication between the beneficiary/family; beneficiary and family education, including healthy lifestyle changes; and coordination of carved-out and linked services, and referral to appropriate community resources and other agencies.
Complex case management services are provided by the PCP, in collaboration with the managed care plan, and include at a minimum: basic case management services; management of acute or chronic illness, including emotional and social support issues by a multidisciplinary case management team; intense coordination of resources to ensure the beneficiary regains optimal health or improved functionality; development of care plans specific to individual needs; and an assessment of transitional needs of beneficiaries into and out of complex case management services.
Medi-Cal Managed Care Key Milestone
1973: Contra Costa Health Plan, the first county-sponsored health plan in California, established to serve Contra Costa County
1982: California legislation authorized the first COHS to offer managed care services to Medi-Cal beneficiaries
1982: Community Health Group established to offer services in San Diego County
1983: Santa Barbara Regional Health Authority (now known as CenCal Health), the first COHS, established to serve Santa Barbara County
1987: Health Plan of San Mateo established
Medi-Cal begins expansion of managed care
CalOptima established to serve Orange County
Partnership HealthPlan of California established to serve Solano County
San Francisco Health Plan established to serve San Francisco County
1995: Kern Health Systems established to serve Kern County
Alameda Alliance for Health established to serve Alameda County
Central Coast Alliance for Health (now known as Central California Alliance for Health) established to serve Santa Cruz County
Health Plan of San Joaquin established to serve San Joaquin County
Inland Empire Health Plan established to serve Riverside and San Bernardino Counties
L.A. Care Health Plan established to serve Los Angeles County
Santa Clara Family Health Plan, established to serve Santa Clara County
Central California Alliance for Health expanded to serve Monterey County
Partnership HealthPlan of California expanded to serve Napa County
2001: Partnership HealthPlan of California expanded to serve Yolo County
2008: CenCal Health expanded to serve San Luis Obispo County
CalViva Health established to serve Fresno, Kings and Madera Counties
Gold Coast Health Plan established to serve Ventura County
Central California Alliance for Health expanded to serve Merced County
Partnership HealthPlan of California expanded to serve Sonoma County
Partnership HealthPlan of California expanded to serve Marin and Mendocino Counties
Transition of seniors and persons with disabilities (SPDs) into managed care in non-COHS counties
First dual eligible (Cal MediConnect) pilots implemented
Medi-Cal managed care rural expansion implemented
Health Plan of San Joaquin expanded to serve Stanislaus County
Partnership HealthPlan of California expanded to serve Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou, and Trinity Counties
ACA Medicaid eligibility expansion to childless adults
Managed Long-Term Services and Supports (MLTSS) program launched in 7 counties
Mild-to-moderate mental health services added to Medi-Cal managed care
2016: Medi-Cal eligibility expanded to include all low-income children regardless of immigration status