Medi-Cal is California’s Medicaid program, which provides health care coverage to many Californians based on a variety of factors including income, adoption/foster care status, and disability. Medi-Cal will always be secondary coverage for children with private primary insurance, but it can help fill some of the funding gaps by covering coinsurance payments and other out-of-pocket expenses when your child sees Medi-Cal-contracted providers. Medi-Cal may also fund medical supplies (such as diapers and g-tube formula) and durable medical equipment. 

Medi-Cal for children is administered through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Some services that are not available to adults with Medi-Cal may be available under EPSDT.
 


  What Services Does Medi-Cal Provide?

Common Medi-Cal services include (but are not limited to):

  • Medical coverage
     
  • Physical and occupational therapy and speech when medically necessary
     
  • Applied Behavioral Analysis (ABA; managed care plans only)
     
  • Equipment and supplies
     
  • Incontinence supplies
     
  • Home nursing care
     
  • In-Home Supportive Services (IHSS)
     


  Who Is Eligible?

Eligibility for Medi-Cal is usually based on household income. However, California offers several programs that allow people with disabilities to obtain Medi-Cal if their income is too high to qualify based solely on financial need. (These include, among others, the Medically Needy Share of Cost Program, the Aged and Disabled Federal Poverty Level program, and the 250% Working Disabled Program, which may be useful for young adults with disabilities whose monthly income is too high for the other programs.) 

The program most often utilized by the families of children with developmental disabilities is the institutional deeming waiver for individuals with developmental disabilities. This program allows children who are Regional Center clients to receive Medi-Cal without regard to family income. For children with private health coverage, Medi-Cal coverage will be considered secondary insurance, and may cover out-of-pocket expenses when you see a provider who accepts Medi-Cal. 

To qualify for Medi-Cal under the institutional deeming waiver for people with developmental disabilities, the Regional Center consumer must:

  • live at home with their family;
     
  • have a valid Social Security number; 
     
  • be ineligible for Medi-Cal due to family income; 
     
  • be diagnosed with a developmental disability; 
     
  • have two or more qualifying conditions in the areas of self-help, motor functioning, social/emotional functioning, special health care conditions, or extensive medical needs, such that the child meets the criteria for an intermediate care facility for individuals with developmental disabilities (ICF-DD); and
     
  • receive at least one funded Regional Center service and utilize that service at least once per year. Many families fulfill this requirement via respite hours. 
     


  Types of Medi-Cal

Medi-Cal as a Primary Provider: Managed Care

  • In the absence of a private primary insurer, most children will be enrolled in a Medi-Cal managed care plan. For Los Angeles County, those managed care plans include HealthNet and LA Care or a contracted plan under LA Care, such as Anthem Blue Cross, Blue Shield of California Promise Health Plan, and, under limited circumstances, Kaiser Permanente (usually for past/recent Kaiser patients). 
     
    • These plans operate like any other managed care plan. You will receive an enrollment packet and both a Benefits Identification Card (BIC) and a managed care health plan card, along with instructions for finding in-network providers. New Medi-Cal recipients are encouraged to call Health Care Options and select a plan. If they fail to do so, one will be chosen for them. 
       
  • For families whose primary insurance is an HMO that is also offered by Medi-Cal, it may sometimes be permissible to enroll in the same Medi-Cal HMO, if available, for simplicity’s sake. Medi-Cal typically covers what the primary insurance doesn’t.


Medi-Cal as a Secondary Provider: Fee-for-Service (“Straight”) Medi-Cal

  • For families whose primary insurance is a PPO, it is difficult to adhere to the preauthorization and referral requirements of a secondary managed care plan. Therefore, families with a private PPO are generally expected to remain on Fee-for-Service (FFS) Medi-Cal, also known as “straight” Medi-Cal. You must provide proof of primary insurance to Medi-Cal’s Health Care Options department to remain enrolled in straight Medi-Cal. Our Public Benefits Specialist, Lisa Concoff Kronbeck, notes: “Generally, people with private insurance are required to enroll in FFS Medi-Cal, but we are receiving inconsistent information from Medi-Cal as to whether that is enforced or whether switching to FFS is optional.”
     
  • If a child has multiple insurance plans, Medi-Cal is always the last provider to be billed. The child’s private insurance bears the primary responsibility for health care coverage. Any other secondary private insurance must be billed before Medi-Cal will cover the service.
     
  • If there are remaining costs or copayments after the primary insurance pays its share, Medi-Cal can be billed for the amount not covered by the primary insurance *if* the provider is contracted with the specific form of Medi-Cal the child receives.
     
  • If a service is denied by the primary insurance, a written denial should be submitted along with the request for Medi-Cal funding.
     
    • Example: A child requires a medically necessary piece of medical equipment that is excluded by the primary insurer. The parents should request a written denial. Once the written denial is received, parents can approach a DME company contracted with Medi-Cal and present the prescription, a copy of the written denial, and their benefits ID card (BIC).


Treatment Authorization Requests (TARs)

Some services and medications require prior authorization by Medi-Cal. The provider will submit the TAR and check its status. If the TAR is denied and you disagree with the decision, you may be able to request a fair hearing. 

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