Medi-Cal

Medi-Cal is California's version of the Medicaid (see side bar) health care program. This program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by federal and state taxes.

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Learn more about Medicaid

Medi-Cal Managed Care

Medi-Cal Managed Care provides high quality, accessible, and cost-effective health care through managed care delivery systems.

Medi-Cal Managed Care contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care. Managed care plans are a cost-effective use of health care resources that improve health care access and assure quality of care.

Today, approximately 10.8 million Medi-Cal beneficiaries in all 58 California counties receive their health care through six main models of managed care: Two-Plan, County Organized Health Systems (COHS), Geographic Managed Care (GMC), Regional Model (RM), Imperial, and San Benito. Medi-Cal providers who wish to provide services to managed care enrollees must participate in the managed care plan’s provider network.

Insight on Managed Care Models

Currently, Medi-Cal has six managed care models. Each County in Medi-Cal managed care uses one of these models. The two most widely used models are:

Two-Plan- This model has two competing Medi-Cal managed care plans in the same County. One of the plan is organized and governed by the County, called the "Local Initiative". The other is a commercial plan, such as Blue Cross, Health Net, etc. Both plan types are Knox-Keene licensed.

County Organized Health System (COHS)- This model has only one Medi-Cal Managed Care plan in the County. This plan is organized and administered by the County.

Learn More About Medi-Cal Managed Care

What Does Medi-Cal Cover?

Medi-Cal Benefits

Medi-Cal currently provides a core set of health benefits, including doctor visits, hospital care, immunization, pregnancy-related services and nursing home care. The Affordable Care Act ensures all Medi-Cal health plans offer what are known as Essential Health Benefits (EHB). These comprehensive services include the ten following categories:

Outpatient (Ambulatory) services
Emergency services
Hospitalization
Maternity and Newborn care
Mental Health and Substance Use Disorder Services
Prescription Drugs
Programs such as physical and occupational therapy (known as Rehabilitative & Habilitative Services) and devices
Laboratory services
Preventive and wellness services & chronic disease management
Children’s (Pediatric) services, including oral and vision care.

Insight

Even though Medi-Cal has these benefits, this does not mean Medi-Cal Managed Care Plans administer and pay for all of them. Some benefits are "carved out" of a Managed Care Plan but are available directly from fee-for-service Medi-Cal.

Different models of Medi-Cal Managed Care Plans may cover different benefits under their State contract. For example, Two-Plan models currently do not cover long-term care; whereas, County Organized Health Systems do.

Click Here for a Benefit Summary Chart

Medi-Cal

Medi-Cal

Medi-Cal Managed Care

Insight on Managed Care Models

What Does Medi-Cal Cover?

Medi-Cal Benefits

Insight

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