Medi-Cal is a health insurance program that helps low-income people get medical care. It can help you pay for doctor visits, hospital stays, prescription drugs and rehabilitation services.
In addition, it provides coverage for children and adults with disabilities. Medi-Cal covers millions of Californians.
Basic Health Benefits
Many low-income individuals in California are covered by Medi-Cal, which includes children and their parents, pregnant women, seniors, and non-elderly adults.
It offers a broad range of services within federal guidelines and is the foundation of the state’s health care safety net.
In addition to its essential health benefits, it also offers a variety of Medi-Cal benefits in California that can be added to your coverage. These options may include specialty care, dental care, vision care and prescription drug benefits.
To determine your eligibility for the program, you must meet one of the following income requirements:
The Medi-Cal eligibility requirements are based on Modified Adjusted Gross Income (MAGI), your taxable income from the previous year as reported on your household tax return. If you have a countable family income below 138% of the Federal Poverty Level, you can qualify for expanded Medi-Cal (modified Medicaid).
If you have a countable income over 138% of the FPL, you are eligible for non-expanded Medi-Cal. You will continue to be subject to the asset/property test.
Your county’s employment and human services department can help you enroll in health care programs, including Medi-Cal or subsidized coverage plans through Covered California. It is called special enrollment, and you can immediately start the next open enrollment period.
Medically Necessary Benefits
Medi-Cal offers medically necessary benefits, or “managed care,” to help cover your health costs. These managed care plans are contracted with providers and clinics that provide you with a comprehensive set of services. A Benefits Identification Card (BIC) will be sent to you, along with information on where to find in-network clinics and providers that provide these services.
A service is typically considered medically necessary if it is calculated reasonably to avoid, identify, or treat a condition that poses a risk to life, causes discomfort or pain, or threatens physical deformity or malfunction, or if no other course of treatment that is equally effective is available or appropriate for the member.
In addition, the service must be of a quality that meets professionally recognized standards and is provided in a manner that is clinically appropriate and will aid in a member’s overall physical or mental well-being.
A medically necessary service is a covered service determined by the state to be reasonable, necessary and consistent with generally accepted professional standards. The service must be based on peer-reviewed publications, expert pediatric, psychiatric and medical opinions and community acceptance.
Medi-Cal can also be used as secondary insurance to help bridge gaps in primary coverage by eliminating co-pays and other out-of-pocket expenses when you visit a Medi-Cal-contracted provider or when your child uses Medi-Cal-contracted services like In-Home Supportive Services. If you need assistance utilizing Medi-Cal as secondary insurance or would like more information, contact your local county office today.
Dental Benefits
Almost everyone in California is eligible for Medi-Cal benefits, which include dental coverage. If you qualify, you will get a Medi-Cal ID card, and you will be able to see any dentist who accepts Medi-Cal.
Medi-Cal offers basic health insurance, coverage for medically necessary services, and dental, vision, and other supplemental (non-Medicare) benefits. You can get more information about these benefits at Medi-Cal’s website.
If you are in a Medi-Cal dental plan, the state pays the dentist directly for the covered services you receive. However, if you are not in a managed care plan, you must find a provider who accepts your chosen program and then visit that dentist.
Most people use Medi-Cal to pay for the basics, like regular checkups and cleanings, but if you need restorative care, Medi-Cal can help with that too. Getting a root canal can cost thousands of dollars, but Medi-Cal will pay for it.
Most Medicare Advantage enrollees can access some dental coverage, although it varies across plans and by service category. Most programs offering preventive dental benefits do not charge any cost-sharing, though some require copayments for these services. More extensive services may be subject to annual plan limits, and coinsurance for these services varies between plans. In addition, some programs include a yearly maximum limit on the amount they will pay for dental coverage.
Vision Benefits
Medi-Cal offers many vision benefits, including routine eye exams and eyeglasses. These are all considered medical services, so you don’t need to worry about a deductible or co-pay.
Having healthy vision is crucial for everyday life and helps prevent long-term health issues such as diabetes, which can be debilitating to the eyes. Having an up-to-date prescription for eyeglasses or contact lenses is also important.
However, the quality of vision care is often lower than people expect. It is partly due to a lack of access to affordable eye doctors who accept Medicaid and the high costs of prescription glasses and contact lenses.
For those with limited incomes, the ability to see and read clearly can be essential in getting through the day. Therefore, it is necessary to have regular eye exams with a reputable eye doctor who can treat your eye health needs and prescribe the correct lens for you.
Generally, the more frequent the eye exams are, the better your eyesight will be. If you have a history of eye problems, your ophthalmologist may recommend that you have eye exams more frequently than once every 24 months.
