California Government Benefits Programs

Medicaid, instituted in 1965, is a Federal/State entitlement program that pays for medical assistance for individuals and families with low incomes and resources. It is the largest source of funding for medical and health-related services for America’s poorest people.

Within broad federal guidelines, each state

  • Establishes its own eligibility standards;
  • Determines the type, amount, duration and scope of services;
  • Sets the rate of payment for services;
  • Administers its own program.

States have broad discretion in determining which groups their Medicaid program will cover and the financial criteria for eligibility. To be eligible for Federal funds, however, states are required to provide Medicaid coverage for certain individuals. These may not be the poorest people, as low-income is only one test of eligibility. These federal criteria are:

  • Individuals that meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996.
  • Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL).
  • Pregnant women whose family income is below 133% of the FPL (services limited to pregnancy).
  • Supplemental Security Income (SSI) recipients in most states.
  • Recipients of adoption or foster care.
  • All children born after September 30, 1983 who are under age 19, in families with incomes at or below the FPL.
  • Certain Medicare beneficiaries.

States also have the option of providing Medicaid coverage for other groups.

The Medicaid-Medicare Relationship

Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For persons enrolled in both programs, any services that are covered by Medicare are paid before any payments are made by the Medicaid program, as Medicaid is always the “payer of last resort.”

California’s Medicaid Program

The California Medicaid program, Medi-Cal, is the largest Medicaid program serving 6.5 million people and second largest in terms of the amount of money spent: $34 billion.  Federal funds make up 55% of Medi-Cal’s budget.  The program:

  • Insures low-income children, parents, blind, elderly and disabled.
  • Insures 1 in 6 Californians under the age of 65 and 1 in 4 children.
  • Insures children, birth to age 1, from families with income at or below 200%  FPL.
  • Insures children, ages 1-5, from families with income at or below 133% FPL.
  • Insures children, ages 6-18, from families with income at or below 100% FPL.
  • Draws more than $19 billion in federal funds.
  • More than half of the Medi-Cal budget is used to pay for the medical and long term care of the elderly and people with disabilities.

Eligibility

There are several different Medi-Cal programs designed to offer different advantages to different target populations. Eligibility differs depending upon the program. There are 7 categories of eligibility requirements:

  • Citizenship status
  • California residency
  • Income
  • Eligibility for other public assistance programs
  • Family assets
  • Institutional status
  • Deprivation

As with federal Medicaid funding requirements, income is only one category for determination of Medi-Cal eligibility. Furthermore, as there is a wide range of considerations that the programs use to determine net income, it is difficult to give an example and have it truly represent the income of that individual or be representative of income eligibility for other Medi-Cal programs. However, as a reference, in the Section 1931 program – Adults with Deprived Children – an adult with one child would need to earn a net income of $9312/year to be eligible for this program. A family of four would need to have a net income of $18,852 to be eligible. In the Medically Needy program, which would cover a blind or disabled person, a single adult’s net income could range from $7200/year to $12,000/year to be eligible.

Dental Benefits

The dental portion of the Medi-Cal program is called Medi-Cal Dental Services. This includes the fee-for-service program (known as Denti-Cal), as well as dental managed care programs. Dental managed care operates on a voluntary basis in LA, Riverside, and San Bernardino counties, serving approximately 200,000 beneficiaries. The agreement with the Department of Health Care Services is to allow this voluntary participation up to a maximum of 350,000 beneficiaries.

Mandatory managed care, referred to as Geographic Managed Care (GMC), operates in Sacramento and San Diego counties. San Diego chooses to receive a capitated amount from the state and reimburses dentists on a fee-for-service basis set by the county. Sacramento is directly capitated, operating though several plans that have contracts to meet state requirements and standards of care. The plans, however, negotiate directly with providers and, in order to provide the access to services their contract requires, some plans reimburse specialists at usual and customary levels.

Via SBX1 26, several changes intended to lower program costs and reduce fraud were made to the Denti-Cal program in October 2003. These include the elimination of laboratory processed crowns on posterior teeth for adults, reduction of fees for scaling and root planning, and the establishment of a four filling threshold for pre-treatment x-ray submission for post-treatment claims.

Before the October 2003 changes, the Denti-Cal program cost approximately $800,000,000/year; $400,000,000 in general fund dollars and $400,000,000 in federal dollars. Preliminary analysis of the first eight months after program changes, from October 2003 to June 2004, show savings of approximately $40,000,000. The current estimated yearly cost for Denti-Cal is approximately $650,000,000-$700,000,000. As there are more Denti-Cal beneficiaries now than pre 2003, the program savings are actually larger than the pure figures indicate.

On January 1, 2006, the Department of Health Services implemented changes in covered benefits as set forth in Assembly Bill 131 (Chapter 80 of the 2005-2006 Session). Beginning January 1, 2006 through January 1, 2009, dental services to individuals 21 years of age or older will be limited to $1,800 per beneficiary for each calendar year.  The limitation does not apply to:

1) Emergency dental services.
2) Services that are federally mandated, including pregnancy-related services.
3) Dentures.
4) Maxillofacial and complex oral surgery.
5) Maxillofacial services, including dental implants and implant-retained prostheses.
6) Services provided in long-term care facilities.

DHS anticipates approximately 15,000 to 20,000 beneficiaries of the 6.2 million eligible for services under the Medi-Cal Dental Program will be impacted.

State Children’s Health Insurance Program (SCHIP)

The Balanced Budget Act of 1997 created a new children’s health insurance program called SCHIP. This program gave each state permission to offer health insurance for children, up to age 19, who are not already insured. SCHIP is a state administered program and each state sets its own guidelines regarding eligibility and services.

California’s SCHIP Program

In California, the SCHIP program is called Healthy Families. It is jointly funded by the federal and state governments and administered by the Managed Risk Medical Insurance Board (MRMIB). Healthy Families provides insurance to children of families whose incomes are too high to qualify for Medi-Cal, but are below 250% of the FPL (about $38,600 for a family of 3). The program:

  • Insures ~800,000 children.
  • Covers a range of diagnostic, preventive and treatment services determined to be medically necessary.
  • Pays through managed care plans.
  • Costs between $4 and $15 per child per month, with a maximum of $45 for the family.
  • Charges $5 co-payment for non-preventive and non-restorative dental services (such as oral surgery, endodontic, and prosthodontic services).
  • Uses federal (67%) and state (33%) revenues.

Excludes children who:

  • Have been covered by health insurance during the previous 3 months;
  • Are not U.S. citizens or legal residents.

What is California Children’s Services (CCS)?

CCS is a statewide program that treats children with certain physical limitations and chronic health conditions. It is managed by the Department of Health Care Services, but administered through counties. The large counties own their own programs and the smaller counties share the operation of their programs with state regional offices in Sacramento, San Francisco and Los Angeles. It is funded with state, county and federal taxes, with some fees paid by parents.
The program is open to anyone who

  • is under 21 years old;
  • has or may have a medical condition that is covered by CCS;
  • is a resident of California; and
  • has a family income of less than $40,000 as reported as the adjusted gross income on the state tax form; or
  • the out-of-pocket medical expenses for a child who qualifies are expected to be more than 20 percent of family income; or
  • the child has Healthy Families coverage.

In general, the conditions covered by CCS are physically disabling or require medical, surgical or rehabilitative services. For example, congenital heart disease, neoplasms, blood disorders, serious birth defects, disorders of the nervous, endocrine, musculoskeletal and immune systems are all covered by CCS services. Medically handicapping malocclusion is a CCS covered benefit.

What are CHDP and EPSDT?

Administration of Medicaid benefits for children younger than 21 is shared between two entities – California’s Child Health and Disability Prevention (CHDP) and the federally mandated Early Periodic Screening, Diagnosis and Treatment (EPSDT).

CHDP is a state and federally funded health program that promotes early detection and prevention of disease and disability, and serves infants, children and teens eligible for full-scope Medi-Cal benefits. The program is responsible for the development and implementation of EPSDT standards for the provision of quality preventive health services to eligible children and links children to needed resources and health care coverage.

The EPSDT program consists of two mutually supportive, operational components:
(1) assuring the availability and accessibility of required health care resources; and (2) helping Medicaid recipients and their parents or guardians effectively use these resources. These components enable Medicaid agencies to manage a comprehensive child health program of prevention and treatment, to seek out eligible children and inform them of the benefits of prevention and the health services and assistance available, and to help them and their families use health resources.

EPSDT requires early and periodic screening and diagnosis of eligible Medicaid recipients under age 21 to ascertain physical and mental defects, and provides treatment to correct or ameliorate defects or chronic conditions found. The agency provides “periodic comprehensive child health assessments,” using the CHDP guidelines.

Annual dental referrals are recommended for children under 21, beginning at age 1 and are mandatory beginning at age 3, regardless of whether a dental problem is detected or suspected. If a health care provider maintaining a contract with Medi-Cal to provide services cannot furnish the dental service, he or she must refer the patient to a dentist or refer the patient to a Medicaid agency who will handle the referral.
Resources:

Updated January 2005