Navigating Medi-Cal Managed Care Plans by County

For those searching for a list of Medi-Cal managed care plans, here's a quick overview of the types of managed care plans available in various counties of California:

• County Organized Health Systems (COHS)
• Geographic Managed Care (GMC)
• Two-Plan Model
• Regional Model

Medi-Cal is California's Medicaid program, providing health coverage to low-income residents. The managed care system is a vital part of this program, covering nearly 90% of Medi-Cal beneficiaries. With multiple models and numerous plans to choose from, it can be overwhelming to steer your options.

Understanding Medi-Cal managed care plans is essential to ensuring you receive the appropriate health benefits. Many counties will experience changes in their available plans next year, which makes staying informed even more crucial.

I'm Marty Burbank, an expert in elder law and estate planning. With years of experience, I've helped countless individuals and families steer the complexities of Medi-Cal managed care plans. Let's dig into the specifics so you can make an informed choice for your healthcare needs.

Overview of Medi-Cal Managed Care Plans

Medi-Cal is California's Medicaid program, providing health coverage to low-income residents. Nearly 90% of Medi-Cal beneficiaries receive care through managed care plans. These plans offer a variety of health benefits and services, ensuring that beneficiaries receive comprehensive care.

Types of Managed Care Plans

Managed care plans come in different types, each with its own structure and benefits. Here's a quick overview:

• HMO (Health Maintenance Organization): Requires members to use a network of doctors and hospitals. Primary care providers (PCPs) manage overall care and provide referrals to specialists.
• PPO (Preferred Provider Organization): Offers more flexibility in choosing healthcare providers. Members can see specialists without referrals but pay less for using in-network providers.
• POS (Point of Service): Combines features of HMOs and PPOs. Members choose between HMO and PPO services each time they need care.
• EPO (Exclusive Provider Organization): Similar to PPOs but does not cover out-of-network care, except in emergencies.
• MCO (Managed Care Organization): These are broader entities that can include HMOs, PPOs, and other plan types to provide coordinated care.

Models of Medi-Cal Managed Care

California employs various models to deliver Medi-Cal managed care. Here's a breakdown:

• County Organized Health Systems (COHS): In this model, a single health plan administers Medi-Cal benefits in a county. All beneficiaries in these counties are mandatorily enrolled in the COHS plan.
• Geographic Managed Care (GMC): Multiple health plans operate in specific geographic areas. Beneficiaries can choose from these plans.
• Two-Plan Model: In counties using this model, there are typically two health plans—one local initiative and one commercial plan. Beneficiaries select between the two.
• Regional Model: Used in less populated areas, this model allows for a mix of health plans to serve larger regions.

Eligibility and Enrollment

Eligibility for Medi-Cal is determined through County Social Services Agencies (SSAs) and the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS). Applications can be done online, in person, or by mail. Once eligible, beneficiaries receive a Benefits Identification Card (BIC) and can choose or be assigned a managed care plan.

Beneficiaries then select a primary care provider (PCP) within their plan's network. If no PCP is chosen, one will be assigned. Beneficiaries can change their PCP at any time by contacting their health plan's member services.

Key Points to Remember

• Eligibility: Determined through SSAs and CalHEERS.
• Enrollment: Beneficiaries receive a BIC and choose a managed care plan.
• PCP Selection: Choose or be assigned a primary care provider within the plan's network.

Understanding these types and models of managed care plans can help you steer the Medi-Cal system more effectively.

Next, we'll dive into the county-by-county breakdown of Medi-Cal managed care plans for 2024.

List of Medi-Cal Managed Care Plans by County

In 2024, Medi-Cal managed care plans will see significant changes across many California counties. Below is a county-by-county breakdown of the plans available, highlighting notable changes such as plan exits and new entries.

Northern California Counties

Anthem Blue Cross, Health Net, Kaiser Permanente

• Alameda County:
• Plans: Anthem Blue Cross, Alameda Alliance for Health

• Changes: No significant changes

• Sacramento County:

• Plans: Anthem Blue Cross, Health Net, Kaiser Permanente

• Changes: Kaiser Permanente expanding services

• Sonoma County:

• Plans: Partnership HealthPlan of California
• Changes: No significant changes

Central California Counties

Partnership HealthPlan, Central California Alliance for Health

• Fresno County:
• Plans: Anthem Blue Cross, CalViva Health

• Changes: No significant changes

• Merced County:

• Plans: Central California Alliance for Health

• Changes: No significant changes

• San Joaquin County:

• Plans: Health Plan of San Joaquin, Kaiser Permanente
• Changes: No significant changes

Southern California Counties

L.A. Care Health Plan, Inland Empire Health Plan

• Los Angeles County:
• Plans: L.A. Care Health Plan, Health Net, Molina Healthcare

• Changes: Anthem Blue Cross exiting

• San Diego County:

• Plans: Community Health Group, Kaiser Permanente, Molina Healthcare

• Changes: No significant changes

• Riverside County:

• Plans: Inland Empire Health Plan, Molina Healthcare
• Changes: No significant changes

2024 Changes

• Plan Exits: Anthem Blue Cross will be exiting Los Angeles County.
• New Plans: Kaiser Permanente will be expanding services in Sacramento County.
• Noteworthy Changes: The transition of services and management responsibilities could affect service availability and provider networks.

For a complete and detailed list of Medi-Cal managed care plans by county, you can visit the Medi-Cal Managed Care Health Plan Directory.

Understanding the available plans in your county and any upcoming changes can help you make informed decisions about your health care coverage. Next, we'll explore the key features of Medi-Cal managed care plans.

Key Features of Medi-Cal Managed Care Plans

Network Adequacy Standards

Medi-Cal managed care plans must meet strict network adequacy standards to ensure beneficiaries have access to necessary health services. These standards are set under the Knox-Keene Act and are further specified by the Department of Health Care Services (DHCS).

Primary Care and Specialty Care:
– Primary care and hospital services must be available within 10 miles or 30 minutes of your residence.
– Specialty care access varies by county size. In larger counties, it must be available within 15 miles or 30 minutes of your home.

Pharmacy Services:
– Pharmacy services must be within 10 miles or 30 minutes of your residence.

Provider Ratios:
– Each plan must have one primary care physician (PCP) for every 2,000 beneficiaries.
– One full-time equivalent physician for every 1,200 beneficiaries.
– One non-physician medical practitioner for every 1,000 beneficiaries.

Emergency Services:
– Must be available 24 hours a day, seven days a week.

These standards ensure that you can access necessary care without excessive travel or wait times. For more details, you can check the full set of network adequacy standards on the DHCS website.

Timely Access Standards

Timely access to care is another crucial feature of Medi-Cal managed care plans. These standards ensure that you can get appointments when you need them.

Appointment Wait Times:
– Urgent care without prior authorization: within 48 hours.
– Non-urgent primary care: within 10 business days.
– Specialist appointments: within 15 business days.
– First prenatal visit: within 10 business days.

Telephonic Medical Advice:
– Providers must have procedures for triaging members' phone calls and providing telephonic medical advice.
– Access to interpreters must be available as needed.

After-Hours Care:
– Providers must ensure a licensed professional is available to answer after-hours calls.

These standards are in place to make sure you receive timely and appropriate medical care. For the complete set of timely access standards, visit the DHCS website.

Member Services

Medi-Cal beneficiaries have specific rights and services designed to help them steer their health care.

Member Services Guide:
– Includes information about covered benefits, accessing services, selecting and changing PCPs, after-hours care, emergency care, specialist referrals, and filing grievances or appeals.

Grievances and Appeals:
– Beneficiaries can voice grievances about the health plan or care received, either verbally or in writing.
– Appeals can be made against health plan decisions regarding coverage and benefits. The health plan appeals process must be exhausted before requesting a Medi-Cal State Fair Hearing.

Care Coordination

Care coordination is essential for managing your health effectively, especially if you have complex or chronic conditions.

Coordinated Care:
– Medi-Cal managed care plans provide coordinated care to ensure all your health needs are met seamlessly.
– This includes managing referrals to specialists and ensuring timely follow-ups.

Understanding these key features can help you make the most of your Medi-Cal managed care plan and ensure you receive the care you need.

Next, we'll answer some frequently asked questions about Medi-Cal managed care plans.

Frequently Asked Questions about Medi-Cal Managed Care Plans

What is a managed care plan for Medi-Cal?

A managed care plan for Medi-Cal is a type of health insurance that contracts with a network of doctors, hospitals, and other healthcare providers to deliver care to Medi-Cal beneficiaries. These plans aim to provide comprehensive health coverage to low-income individuals and families in California.

Key Points:

• Network-Based Care: Managed care plans use a network of providers to offer services. This helps control costs and ensures quality care.
• Primary Care Focus: Beneficiaries usually select a primary care provider (PCP) who manages their overall healthcare.
• Coordinated Services: These plans emphasize coordinated care, making it easier for patients to get the services they need.

How many managed care organizations are there in California?

California has a total of 24 managed care organizations that contract with the Department of Health Care Services (DHCS) to provide Medi-Cal services. Of these, 17 are local health plans.

Facts and Stats:

• DHCS Oversight: Medi-Cal managed care plans are regulated by DHCS in collaboration with the Department of Managed Health Care (DMHC).
• Beneficiary Coverage: Nearly 90% of Medi-Cal beneficiaries receive their care through these managed care plans.

Which types of managed care plans are available?

Medi-Cal offers several types of managed care plans to meet the diverse needs of its beneficiaries:

• Health Maintenance Organization (HMO):
• Requires you to choose a PCP.
• Referrals needed for specialists.

• Lower out-of-pocket costs.

• Preferred Provider Organization (PPO):

• More flexibility in choosing providers.
• No referrals needed for specialists.

• Higher premiums and out-of-pocket costs.

• Point of Service (POS):

• Combines features of HMOs and PPOs.
• Flexibility to choose providers inside and outside the network.

• Requires referrals for specialists.

• Exclusive Provider Organization (EPO):

• Only covers services from providers in the network.
• No need for referrals to see specialists.

• Lower costs compared to PPOs.

• Managed Care Organization (MCO):

• A broad category that includes various types of managed care plans.
• Emphasizes coordinated and comprehensive care.

Understanding these different types can help you select the best plan that fits your healthcare needs and budget.

Conclusion

At OC Elder Law, we understand that navigating the complexities of Medi-Cal managed care plans can be overwhelming. That's why we offer comprehensive legal services to help you and your loved ones make informed decisions about your healthcare and financial future.

Our expertise in Medi-Cal planning, elder law, and estate planning allows us to provide custom solutions that meet your unique needs. Whether you need assistance with selecting the right Medi-Cal plan, preparing for long-term care, or ensuring your estate is managed according to your wishes, we are here to support you every step of the way.

Why Choose OC Elder Law?

• Expertise and Experience: Our attorneys specialize in elder law and have experience in Medi-Cal planning and estate planning.
• Personalized Service: We take the time to understand your specific needs and provide customized solutions.
• Compassionate Support: We offer not just legal advice but also emotional support during difficult times.

Don't leave your family's future to chance. Let us help you secure peace of mind and a harmonious future for your loved ones.

Learn more about our Medi-Cal planning services and book a consultation today.

By choosing OC Elder Law, you are not just another client; you become part of our family. Let's work together to ensure your family's future is secure and harmonious.