A Guide to Medi-Cal - California Medicaid Program

Applying for California Medicaid

California makes it simple for those at or slightly above the poverty line to enroll in California Medicaid by allowing applications in person, online, or by phone, mail, or fax.

If you’re applying in person, locate your nearby social services county office to receive assistance while filling out a form. You can also contact an insurance agent or Covered California Certified Enrollment Counselor on the Covered California website to help you determine your eligibility and how to proceed.

You can also reach your social services county office by:

• Mail: Print the Single Streamlined Application in your preferred language, fill in all required boxes, and send it via USPS.
• Online application: Fill out the form directly on the Covered California website, which instantly and securely transfers your application to the office.
• Phone or fax: Determine your local county office online and use their respective number to call and apply over the phone. You may also find a fax number on their website, allowing you to send a physical copy of your document straight to the office if applicable.

Eligibility Requirements

Knowing how to apply for Medi-Cal begins with checking your eligibility status. First, you must be a California resident and provide your annual income alongside every other household member’s income. Your assets’ value is also an indicator of your net worth, so prepare to answer questions about your property.

While filing taxes is not a qualifying factor for receiving California Medicaid, your filing status is necessary for determining your residence’s yearly earnings and how close you fall to the poverty level. For instance, if you’re a sole resident, making $20,121 qualifies you for benefits. For each additional resident, add $7,094 to the total income to determine the maximum yearly earnings that allow you to become eligible.

You’re also eligible if you:

Getting a California Medicaid Card

If you fall under one or more of the above scenarios, you can fill out and send in your application using one of the above methods. Your local county office will mail you a Notification of Likely Eligibility to confirm whether you can receive benefits. It will reach out for physical verification copies of your income, immigration or citizenship status, and other vital information.

Once all the details are in and your application is complete, the office will send a Final Notice of Action explaining whether it granted or denied you for enrollment. Since the county-level court makes this decision, you can overrule its judgment by appealing to the State Superior Court. Otherwise, if it accepts your application, it’ll send a BIC in the mail within 45 days and relay your available benefits.

Renewing or Replacing Your California Medicaid Card

Once you receive your California Medicaid ID card, you can immediately begin using it by showing your healthcare providers your unique ID number so they can bill Medi-Cal rather than you. However, if you use your card frequently, it’s not uncommon for it to become stolen, lost, or damaged. If this occurs, contact your local county office as you did before to request a new card.

You’ll also receive a new card if inaccurate information is on your current card or your card never appeared in the mail after the 45-to-90-day window.

Depending on how long you’ve had your original card, you’ll likely notice different appearances amongst cards. While the older cards are simple, with blue writing on a white background, newer ones include pictures of California poppies lining the bottom edge. Both types of cards are still acceptable, but each cardholder may only have one valid card at a time.

Although the Medi-Cal card itself doesn’t expire, meaning you don’t receive a new one in the mail unless you ask for one, your coverage needs renewal yearly to remain active. You’ll receive letters alerting you to upcoming deadlines, and you can renew your application with an in-person office visit or by phone, email, mail, or fax. You also keep your card unless you miss your deadline and reapply for benefits.

Medi-Cal Coverage

With Medi-Cal coverage, it’s vital to understand what Medi-Cal covers so you receive assistance when and where you need it. This program offers the same EHB as California Medicaid, meaning it aids with the ambulatory and emergency services alongside the following:

• Maternity, infant care, and pediatrics for mothers and underaged individuals
• Hospitalization
• Substance Use Disorder or SUD
• Behavioral and mental health treatments
• Chronic disease management and wellness services
• Prescriptions
• Laboratory services
• PT and OT

Below, we’ll delve further into some of these care services and how you can benefit from them.

Dental

California Medicaid originally offered Dental Fee-For-Service (FFS) alone across all 58 California counties, which entails showing your dentist your BIC during each visit. In 1995, Dental Managed Care (DMC) became available in Sacramento County with three Geographic Managed Care plans (GMC) and in Los Angeles County with three Prepaid Health Plans (PHP). However, they offer the same services as FFS.

Outside of regularly scheduled semi-annual cleanings, X-rays, and exams, these benefits comprise common and necessary dental procedures like fluoride treatments for sensitive teeth, fillings and anterior root canals, prefabricated crowns, dentures, and more.

Adult benefits also include pregnancy-related and emergency services and any services for intermediate or nursing facility residents and Department of Developmental Services consumers. For those who have more serious dental issues and anticipate requiring more visits to the dentists, investing in private dental plans in California is advisable.

Prescription Drugs

The Medi-Cal program must cover a minimum of one drug from under each U.S. Pharmacopeia drug category to service enrollees. That includes legend drugs or prescription medication in which a medical practitioner prescribes an FDA-approved drug, along with non-legend OTC drugs that don’t require a prescription. If Medi-Cal doesn’t list your medication, contact a consultant for authorization.

OTC products like antihistamines, decongestants, and combination medications are also on the Contract Drugs List alongside compounded drugs that combine two or more substances, which are not FDA-approved.

This California Medicaid program also provides HIV drug treatments and controlled substance policies, the latter providing a 35-day supply automatically for any drug, including opioids. For a larger supply, you’ll need to receive prior authorization.

Extended Health Care

Although some California residents use this program as their primary insurance, others use it as an extended healthcare option, since what Medi-Cal covers, regular insurance may not. For instance, extended healthcare usually covers vision, dental, prescription drugs, professional services and equipment, and various forms of therapy.

If you qualify for Medi-Cal on top of your primary healthcare insurance, the latter receives billing first, and the California Medicaid program covers the remaining costs. It is vital as a beneficiary to report to the federal and state government alongside your local county office that you’re receiving private insurance assistance, so contact them and your healthcare provider if you’re eligible for both.

Travel and Out-of-State Coverage

What is Medi-Cal coverage like outside of the Golden State? If you get into an accident or another emergency once you’re outside the state, you’ll most likely receive assistance after showing your BIC to a healthcare provider. Unfortunately, the program doesn’t cover regular services like picking up prescriptions or having X-rays done, meaning you’ll have to pay out-of-pocket without reimbursement. If you are traveling outside of California for leisure, invest in proper travelers insurance.

Students and Seniors

Anyone under 21 is eligible to apply for Medi-Cal, meaning California students in grades K-12 can receive coverage under their parents. Underaged college students still financially dependent on their families are also eligible, although students don’t need a parent or parental guidance when applying.

Likewise, most residents 65 or older can receive assistance but must acquire full-scope Medi-Cal approval and follow all program rules to gain at-home or institutional care, including from nursing homes. Some long-term care includes nutritional, habilitation, and respite services alongside nursing, personal care, and homemaker services, to name a few.

Coverage for Subgroups

Certain subgroups that qualify for California Medicaid may receive additional benefits under the Medi-Cal program.

Disability

Those with a disability can receive Medi-Cal even with a higher income. As long as you meet the program’s income rules, receive a disability income, and Social Security defines you as someone with a disability, you may be eligible. If your family income falls below the 250% federal poverty line, you’re also eligible.

Anyone enrolled in the 250% WDP used to pay a low monthly premium of between $20 and $250, but after July 1, 2022, you can pay as little as $0 in premiums with the same benefits available to you.

It’s important to note that Medi-Cal may not provide enough coverage in an instance where someone becomes temporarily or permanently disabled. Investing in quality disability insurance is an excellent way to assist with some of the costs incurred with not being able to work, and to help with the cost of medical needs.

Military

The DHCS Veterans Benefits Enhancement Project allows all who have served and their families to receive federal benefits under Medi-Cal in the form of pensions or compensation, medical and prescription drug coverage, family benefits, and medical equipment.