Medi-Cal is California’s part of a national health coverage program called Medicaid. Each state runs its own Medicaid program. The states have to follow certain national Medicaid rules, but they have flexibility in how they run their programs. The state Medicaid programs are paid for with a combination of county, state, and federal money.
You can think of Medi-Cal as a single program that you can qualify for in many different ways. The different ways to get Medi-Cal are called eligibility categories. There are over 90 eligibility categories, each with its own rules and requirements.
This article will explain the Medi-Cal benefit in more detail and describe some of the most common eligibility categories for people with disabilities. It will also explain how you can keep your Medi-Cal coverage if you lose it because of a change in income, and how Medi-Cal may help pay for the premiums of other insurance programs.
Medi-Cal pays for a wide variety of medical expenses:
Primary Medical Care
Ongoing Care & Recovery
Other medical related costs
Depending on how you qualify for Medi-Cal, the program may pay for all of these services (full-scope Medi-Cal) or just some of them (partial-scope Medi-Cal).
Like other health coverage plans, Medi-Cal has rules about what it will cover. For example, Medi-Cal only pays for prescriptions that are on its list of accepted drugs. Along the same lines, it may refuse to pay for certain procedures like cosmetic surgery, and it will require that you get prior authorization for some services. If Medi-Cal decides not to pay for something and you think it should, you can appeal the decision.
Depending on your situation, you might get employer-sponsored coverage, Medi-Cal, and Medicare all at the same time. This can sound confusing, but it can help you, because one form of coverage may pay for costs that your other coverage won't pay for.
The rules about how your different types of coverage pay for things are very complicated, so it’s important to check with your health coverage plans when you have questions about which plan will pay for what expenses.
Generally speaking, Medi-Cal will only pay for expenses that it covers and that your other coverage won't pay for. The Centers for Medicaid and Medicare Services has a helpful pamphlet on Medicare and Other Health Benefits: Your Guide to Who Pays First.
Note: The Affordable Care Act (ACA) of 2010, has made big changes to our nation’s health care system and there will be more changes over the next few years. DB101 has been and will continue to be updated to reflect these changes. For more information, visit Covered California.