Covered Populations
The legislation that expanded Medicaid eligibility to include childless adults aged 19-64 and brought California's uninsured rate from 14% to 7%.
What is the Affordable Care Act?
Despite participation of more than 400 hospitals and approximately 130,000 doctors, pharmacists, dentists, and other health care providers, people with Medi-Cal coverage are this much more likely to have difficulty finding a primary care provider or specialist than those with commercial or Medicare coverage.
What is twice?
The Medi-Cal delivery system in which the state contracts with health plans and pays a fixed amount each month per member enrolled in the plan. The health plan is then responsible for providing all Medi-Cal covered services included under the contract.
What is managed care?
CalAIM, the name for most recent set of waivers, created a reimbursement pathway for these 14 services, known as community supports.
What are Housing Transition Navigation Services, Housing Deposits, Housing Tenancy and Sustaining Services, Short-Term Post-Hospitalization Housing, Recuperative Care (Medical Respite), Respite Services, Day Habilitation Programs, Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities; Community Transition Services/Nursing Facility Transition to a Home; Personal Care and Homemaker Services; Environmental Accessibility Adaptations (Home Modifications); Medically Tailored Meals/Medically-Supportive Food; Sobering Centers; Asthma Remediation
While Medicare is 100% funded by the federal government, Medicaid is funded by this. In California, it ranges from 50% for the mandatory populations to an enhanced 90% rate for the ACA expansion population.
What is a partnership between states and the federal government, where the federal government pays a share of the cost of the Medicaid program (known as FMAP) based on the state's per capita income?
One third of all Californians, more than half of school age children, and 2/3 of nursing home residents (by bed days).
Who are people whose health care is covered by Medi-Cal?
These providers rely on Medi-Cal for nearly two-thirds of net patient revenues.
What are California's city and county hospitals?
Dental services, Specialty Mental Health Services, Substance Use Services, Personal Care Services, and services for children with special health care needs are examples of these.
What are services carved out of managed care?
The Assisted Living Waiver, In Home Supportive Services, and services for Californians with developmental disabilities are all made possible under this type of waiver, which allows a state to maintain waiting lists and/or cap enrollment.
What are 1915c Home and Community Based Services Waivers?
Outside of the public health emergency, Medi-Cal enrollees must have their eligibility “redetermined” at this interval.
What is one year?
Children, pregnant women, and seniors and persons with disabilities
What are the populations states have to cover?
These entities conduct eligibility determination and enrollment for Medi-Cal and for the In Home Supportive Services program, as well as managing contracts and providing direct services for behavioral health and specialty care for children with special health care needs.
What are California's 58 counties?
Culminating in changes in which commercial plans are available in some markets as well as a new contract for all plans starting in 2024, this competitive re-contracting process has been a focus of the Medi-Cal accountability BOW.
What is reprocurement?
Federal law does not allow Medicaid funds to be used in these settings. California's CalAIM waiver seeks to change that.
What are Institutions for Mental Diseases (large psychiatric hospitals), Jails and Prisons.
As of March 2022, nearly 85% of Medi-Cal enrollees are served through this delivery system.
What is managed care?
People who have both Medicare coverage (over age 65 and/or living with a disability) and Medi-Cal coverage.
What are dual eligibles?
588,000 strong, these Medi-Cal providers provide over 77 million hours of care every month to over 680,000 Medi-Cal enrollees.
Who are In Home Supportive Services (IHSS) providers?
The commercial plans that will have Medi-Cal contracts starting in 2024.
What are Anthem Blue Cross, Health Net, Kaiser Permanente, and Molina?
The three core tenets of the Medicaid program that waivers have been used to modify.
What are statewideness, comparability, and freedom of choice of provider?
In addition to the Single Streamlined Application (which also works for Covered California), people can temporarily enroll in Medi-Cal at hospitals and clinics through this program.
What is presumptive eligibility?
Beginning in 2024, California will provide Medi-Cal coverage to about 700,000 people without satisfactory immigration status in this age group.
What is ages 26-49?
The rate of preventable hospitalization (a measure of primary care access) is this much higher among Medi-Cal enrollees compared to those with commercial insurance.
What is five times?
A strategy whereby a health plan gives a provider organization financial responsibility for clinical services (e.g., professional services, institutional services, ancillary services) and/or administrative and population health functions (e.g., credentialing, utilization management, quality improvement).
What is delegation?
California's Medi-Cal program employs three different types of federal waivers. CalAIM moved most of Medi-Cal managed care from an 1115 Research and Demonstration waiver to this type of waiver, which is considered more stable. In addition, CMS has a 90 day review period rather than the open review period for an 1115.
What is a section 1915b "Freedom of Choice" waiver?
Prenatal vitamins, nutrition counseling, a breast pump, lactation consulting, transportation to medical appointments and the support of a doula are all examples of these.
What are Medi-Cal covered services for birthing people?