Children Now Insider: Medi-Cal 101

What you need to know about California’s public health insurance program

A Q&A with Mike Odeh, Director of Health Policy

March 10, 2020

What is Medi-Cal?

Medi-Cal (California’s version of Medicaid) is a free or low-cost program that provides health coverage to millions of Californians, including more than 5.3 million children in the state. In fact, Medi-Cal is one the big reasons why the rate of uninsured children in California has decreased from 20 percent in the late 1990’s to just 3 percent today.

It’s also important to note that the benefits of having health coverage are wide-ranging, and extend far beyond childhood. Kids who have Medi-Cal miss fewer school days and do better academically, are more likely to graduate from high school and enter college, have fewer emergency room visits and hospitalizations as adults, and even earn more money as adults.

Who is eligible?

Medi-Cal eligibility is income-based; and low-income children, pregnant women and families have traditionally been covered by the program. In 2016, Medi-Cal was expanded to include all low-income children and youth under age 19 regardless of immigration status. And this year, thanks to the Health4AllYoungAdults initiative, all young adults up to age 26 can enroll in Medi-Cal.

To learn more about Medi-Cal eligibility and enrollment, please visit this site.

How does Medi-Cal Managed Care work?

Medi-Cal contracts with private managed care or health plans, like Anthem Blue Cross and Kaiser Permanente, to provide health care services for about 90 percent of the kids enrolled in Medi-Cal. These contracts set specific guidelines and expectations for the managed care plans, including that kids get essential preventive care and screenings. As such, nearly all children with Medi-Cal are enrolled in a health plan that is supposed to provide and manage the routine health care services that they need.

What services are babies and children entitled to receive through Medi-Cal?

Children are legally guaranteed to a variety of preventive and medically necessary services through Medi-Cal. The Early & Periodic Screening, Diagnosis & Treatment (EPSDT) benefit applies to all children under the age of 21 and covers a regular schedule of preventive care such as well-child visits, dental, vision, hearing and trauma screenings and vaccinations; timely access to and coordination with language-appropriate care; and any treatments a child may need for a physical or mental condition.

What are some of the current challenges with Medi-Cal?

Unfortunately, not all California kids covered by Medi-Cal are getting the care they need and are entitled to by law.

  • Last year, the State Auditor reported that fewer than half of children in Medi-Cal had an annual health check-up.
  • Research from the California HealthCare Foundation shows that low rates of Medi-Cal children’s health access and quality care have persisted for a decade.
  • The Government Accountability Office, a federal agency and ‘congressional watchdog’, released a report last year showing California ranked 50th among all states for well-baby screening rates in Medi-Cal.

This is in part due to how the state contracts with and pays managed care plans.

Why are so many California babies and children missing out on important screenings and check-ups?

According to the State Auditor, children are not getting the health care services they need due to insufficient access (a problem on the provider side) and poor oversight from the Department of Health Care Services (DHCS), the agency responsible for administering the Medi-Cal contracts.

However, the real problem lies in the fact that payments to managed care plans are not based on their performance. Plans are not rewarded for connecting kids to the care they need, and currently, there are no financial incentives for under-performing plans to improve. Yet managed care plans continue to get paid, even as California kids go without care.

What can the state do to improve Medi-Cal?

It can start with Medi-Cal payment reform – health plans should be paid for delivering quality care to children and ensuring that they receive the services to which are guaranteed in order to improve their health and well-being.

A couple of weeks ago, I provided testimony at an informational Senate hearing Medi-Cal: Oversight of Managed Care Plan Responsibilities and “Medi-Cal Healthier California for All” Proposal on this very issue and highlighted the urgent need for payment reform. Specifically, DHCS should restructure Medi-Cal payments to health plans for children’s services to:

  1. Ensure delivery of preventive care and screenings;
  2. Support care coordination; and
  3. Reward children’s health outcome improvements and establish consequences for failure.

If we want quality care and improved health outcomes for kids, then we should act accordingly. And now is the time to do so – California will be reviewing its Medi-Cal managed care contracts this year – giving us as a state the opportunity to develop strongest-in-the-nation contracts to ensure kids get the health care they need.