California Medicaid Program Q1

CaliforniaMedicaid Program


InCalifornia, Medi-Cal serves as the state’s Medicaid program. It isa public health insurance program that caters for the wellbeing ofmembers from low income families including children, the disabled,senior citizens, individuals in foster care and expectant women. Italso covers individuals suffering from various condition includingtuberculosis, cancer and HIV/AIDS. The state and the federalgovernments are responsible for funding the program. The CaliforniaDepartment of Health services established the program in 1966 and ithas grown to be largest in terms of enrollment in the country. Someof the notable milestones in the development of the program includethe conception of managed care plans in 1973, the implementation ofexclusive contracting of services in hospitals in 1982, the expansionof family planning care in 1997, extension of attention to familiesat 100% of the FPL in 2000 and intensifying coverage to the uninsuredadults in 2010 (California Healthcare Foundation 2).

Currently,the program covers about 11.9 million citizens. This is by far thelargest coverage by any state in the currently. However, the changein the reporting system has seen the number drop from 12.65 millionpeople that were under the program in 2015 to the current 11.9million (California Healthcare Foundation 3). The department ofhealth services removed some of the limited benefit groups from itsofficial Medi-Cal records. Since 2013, the enrollment in the programhas grown by 54%. The 2016-2017 prospects depict a precedent growthfollowing the increased awareness and enrollment (CaliforniaHealthcare Foundation 5).

TheCalifornia Medi-Cal is the largest compared with any other givenstate. Nationally, the Federal Department of Health provides thatabout 70 million citizens are covered by Medicaid. This translates to27% of the total population (America Academy of Pediatrics 2). InCalifornia, more than 11 million citizens enjoy the benefits ofMedi-Cal, and the population is projected to grow by 2017. The figuretranslates to 37% of the citizens inclusive of the all the specialpopulations targeted by the state (Lally and Yegian 3).

Inthe region, managed care is available in 25 counties and it accountsfor 50% of all the beneficiaries. The mandatory groups that must beenrolled include children, pregnant women, and non-disabled parents.The elderly and the disabled are voluntary members. The currentpenetration of managed care in California stands at 51% for fullcapitation compared to the combined nationwide full and partialcapitation of 55% (Lally and Yegian 8). In terms of penetrationspending, the state, and national expenditure stands at 19% as at2016.


InCalifornia, citizens have a variety of managed care plans to choosefrom. In 2011, about 60% of the citizens covered by the Medi-Calprogram were under the umbrella of Managed Care Organizations (MCOs).These cater for acute, primary and specialty care. Majority of thecitizens enrolled under MCOs are children from low-income families,pregnant women, and parents whose subscription to the plan ismandatory (California Department of Health Care Services 9). In 2011,the state government gave a directive to all the elderly and thedisabled who were not covered by Medicaid to switch fromfree-to-service to MCOs (Lally and Yegian 4).

Inaddition, the state provides the Prepaid Health Plans and PrimaryCare Case Management (PCCM) through various models. They includeCounty Organized Health Systems (COHS), Two-Plan Model, GeographicManaged Care, Regional, Imperial and San Benito. The first and oldestis the County Organized Health System (COHS) that was created andadministered by a board of supervisors in the differentjurisdictions. Currently, the plan operates in 22 counties and allmanaged care enrollees are in the same plan. The Two Plan Modeloffers beneficiaries the liberty to choose from a local initiative ora commercial plan. Currently, the model is available in 14 counties(California Department of Health Care Services 16)

TheGeographic Managed Care Model allows beneficiaries to choose servicesfrom two counties. In 2010, the Department of Health through section115 of the state health laws combined the COHS, Two Plan and theGeographic Manage Care to form the Bridge Reform that acts as awaiver program. During the expansion of the managed care program, thegovernment conceived the Imperial and San Benito models in thecounties that were not covered by the other plans. There is also aseparate Medi-Cal Specialty Mental Health Services operated by mentalhealth departments to provide inpatient services, outpatienttreatment, case management and crisis intervention. In terms ofcoverage, services in the two plan model take the Lion’s share of64% and with more than 6.5 million beneficiaries. COHS covers 2.2million citizens translating to 21%, and Geographic Managed care 11%,San Benito Program 1%, Imperial Plan 1% and the Regional Expansioncovering 3% (California Department of Health Care Services 34).


Thereare various payment and reimbursement plans for the various models ofmanaged care in the state. Currently, the government contracts 25MCOs in the different counties. They include state sponsored andnon-profit institutions. The state reimburses a fixed monthlycapitation rate for each member enrolled in the program. The premiumsare determined through actuarial calculations. In addition, thevarious models under PCCM attract payments made through thecapitation program. The state sets aside a capitation payment on amonthly basis for all the enrollees. The reimbursement includes afull payment made by the Department of Health and it includes thecost of administrative services. However, it does not cover lossesincurred in any contractual obligations with the state (CaliforniaDepartment of Health Care Services 31).

Sometimes,the subscribers are required to pay for some services in theinstitutions in which they receive care. The common payments includephysician office visits which should not exceed one dollar per visitand non-emergency services received in a specified and equipped roomthat is not in excess of five dollars. Some drug prescriptions andrefills are also catered for by the enrollee if they do not exceedone dollar. However, the co-payment services do not apply toemergency services or family planning. The cost sharing is alsoexempted for children below the age of 18 years, pregnant women,individuals in foster care and those who are institutionalized.

Inconclusion, California is the biggest spender in healthcare of allthe states in America. More than 28% of the government expendituregoes to providing the citizens with accessible care in the stateMedi-Cal (the state’s version of Medicaid) covers more than 11million members. The coverage exceeds the nation registration of 27%.The state government provides citizens with a myriad of plans tochoose the wide coverage of the MCOs makes the most prefer model ofcare, and it accounts for more than 60% of the managed careexpenditure. The government pays premiums to the hospitals per month.However, a patient may be required to chip in through the costsharing strategy. However, children below 18 years, pregnant women,institutionalized individuals and those in foster care are notrequired to contribute towards the overhead charges. In addition tobeing the largest cove in the state level, Medi-Cal is expected toincrease its membership by 2017 due to the increased awareness andintense enrollments.


AmericaAcademy of Pediatrics. CaliforniaMedicaid Highlights.Children’s Hospital Association, 2016. Print.

CaliforniaDepartment of Health Care Services. Medi-CalManaged Care – Quality Improvement &amp Performance MeasurementReports,2015. Print.

CaliforniaHealthcare Foundation. Medi-CalFacts and Figures. CaliforniaHealthcare Almanac, 2016. Print.

Cunningham,Peter J. &quotThe Effect of Early Medicaid Expansion in Californiaon Safety Net Hospital Utilization.&quot 2015 Fall Conference: TheGolden Age of Evidence-Based Policy. Appam, 2015. Print.

Lally,Sarah and Yegian, Jill. California`sMedi-Cal Managed Care Pay for Performance Landscape.Integrated Healthcare Association, 2015. Print.