Medi-Cal Managed Care
Starting in 2011, the state of California moved most seniors and persons with disabilities (SPDs) who receive Medi-Cal but not Medicare also into Medi-Cal Managed Care.
The Coordinated Care Initiative (described below) is part of California’s move to provide most Medi-Cal in the state through managed care plans to additional SPDs who receive both Medi-Cal and Medicare. More information about Medi-Cal managed care is below.
The federal Medicaid program provides health care to low-income people, including seniors, people with disabilities, and children. Medicaid is funded through a combination of state and federal dollars. States run their own Medicaid programs and have to follow certain federal rules, but have some flexibility in the services they offer.
What can I do if I do not like something my Medi-Cal managed care plan did?
California as of July 1, 2017, is following new federal regulations about how you appeal a decision or dispute about benefits, and about how you bring other matters to the attention of the managed care plan through a grievance. First, it is always best to talk directly with your provider or call your plan’s customer service number. If that does not resolve the issue, you can take one of the following actions.
1. What is managed care?
Managed care is a system for providing and paying for health care services. Managed care means that you receive most of your health care from a managed care plan. A managed care plan is an organized network of health care providers that focuses on primary and preventive care. Hospitals, physicians and other health care providers are members of the network. The managed care plan can be public or private.
1. What are out-of-network services?
Medi-Cal managed care organizations (MCO)1 have networks of providers, including doctors, pharmacies, clinics, labs, and hospitals (“plan providers”). Most of the time, members must use the plan providers when getting medical care in order for services to be covered by the MCO. There are instances when you can get medical services from providers who are not plan providers.
Some mental health services are available through fee-for-service Medi-Cal1 providers or Medi-Cal managed care plans, while others are available only through county Mental Health Plans under the Specialty Mental Health Services Waiver.2 Examples of specialty mental health services include intensive day treatment, day care rehabilitation and adult residential treatment services.3 For more information on specialty mental health services see “Getting Medi-Cal Outpatient Specialty Mental Health Services” Publication 5084.01.4
This fact sheet explains how to obtain transportation to your medical appointments from your Medi-Cal Managed Care Plan (MCP). The end of this publication discusses how to obtain transportation services if you have Fee-For-Service (FFS) Medi-Cal.