Medi-Cal Help Center​​​

Medi-Cal is California’s version of the Federal Medicaid program. Medi-Cal offers no-cost and low-cost health coverage to eligible people who live in California.

The Department of Health Care Services (DHCS) oversees the Medi-Cal program.

Your local county office manages most Medi-Cal cases for DHCS. You can reach your local county office online. You can also call your local county office.

The local county offices use many facts to determine what type of help you can get from Medi-Cal. They include:

• How much money do you make
• Your age
• The age of any children on your application
• Whether you are pregnant, blind or disabled
• Whether you receive Medicare

Most people who apply for Medi-Cal can find out if they qualify based on their income. For some types of Medi-Cal, people may also need to give information about their assets and property.

Did you know?

It is possible for members of the same family to qualify for both Medi-Cal and Covered California. This is because the Medi-Cal eligibility rules are different for children and adults.

For example, coverage for a household of two parents and a child could look like this:

• Parents — eligible for a Covered California health plan and receive tax credits and cost sharing to reduce their costs
• Child — eligible for no-cost or low-cost Medi-Cal

Covered California is the State’s health insurance marketplace. You can compare health plans from brand-name insurance companies or shop for a plan. If your income is too high for Medi-Cal, you may qualify to purchase health insurance through Covered California.

Covered California offers “premium assistance.” It helps lower the cost of health care for individuals and families who enroll in a Covered California health plan and meet income rules. To qualify for premium assistance, your income must be under the Covered California program income limits.

Covered California has four levels of coverage to choose from: Bronze, Silver, Gold, and Platinum. The benefits within each level are the same no matter which insurance company you choose. Your income and other facts will decide what program you qualify for.

To learn more about Covered California, go to www.coveredca.com or call 1-800-300-1506 (TTY 1-888-889-4500).

Note: The myMedi-Cal guide information is available in this Help Center.

myMedi-Cal: How To Get the Health Care You Need tells Californians how to apply for Medi-Cal for no-cost or low-cost health insurance. You will also learn what you must do to be eligible for the program. This guide tells you how to use your Medi-Cal benefits and when to report changes. You should keep this guide and use it when you have questions about Medi-Cal.

Download myMedi-Cal Guide (PDF)

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Medi-Cal offers a wide range of health services known as Essential Health Benefits. They include:

• Outpatient services (doctor visits without staying overnight)
• Emergency services (care for emergencies)
• Hospitalization (staying in a hospital)
• Maternity and newborn care (care for moms and babies)
• Mental health services (help with mental health)
• Substance Use Disorder services (drug or alcohol problems)
• Prescription drugs (medicine from a pharmacy)
• Laboratory services (blood tests and other lab tests)
• Rehabilitative and habilitative services (physical therapy)
• Medical supplies (like wheelchairs and oxygen tanks)
• Preventive and wellness services (check-ups)
• Chronic disease management (care for long-term health issues)
• Pediatric services (health care for kids, including teeth and eye care)
• In-home care (help and care at home)

To find out if Medi-Cal covers a service, ask your doctor or health plan.

Dental health is an important part of overall health. The Medi-Cal Dental Program covers many services to keep your teeth healthy. You can get dental benefits as soon as you are approved for Medi-Cal.

You can see the dental benefits and other resources at https://dental.dhcs.ca.gov/. Or, you can call 1-800-322-6384 (TTY 1-800-735-2922) Monday through Friday between 8:00 a.m. and 5:00 p.m.

Get Medi-Cal Dental Services

The Medi-Cal Dental Program gives service in two ways. One is Fee-for-Service Dental and you can get it throughout California. Fee-for-Service Dental is the same as Fee-for-Service Medi-Cal. Before you get dental services, you must show your BIC to the dental provider and make sure the provider takes Fee-for-Service Dental.

The other way Medi-Cal gives dental services is through Dental Managed Care (DMC). DMC is only offered in Los Angeles County and Sacramento County. DMC plans cover the same dental services as Fee-for-Service Dental. DHCS uses three managed care plans in Sacramento County. DHCS also contracts with three prepaid health plans in Los Angeles County. These plans provide dental services to Medi-Cal beneficiaries.

If you live in Sacramento County, you must enroll in DMC. In some cases, you may qualify for an exemption from enrolling in DMC.

To learn more, go to Health Care Options.

In Los Angeles County, you can stay in Fee-for-Service Dental or you can choose the DMC program. To choose or change your dental plan, call Health Care Options.

Medi-Cal offers inpatient and outpatient settings for drug or alcohol abuse treatment. This is also called substance use disorder treatment. The setting depends on the types of treatment you need. Services include:

• Outpatient Drug Free Treatment (group and/or individual counseling)
• Intensive Outpatient Treatment (group counseling services provided at least three hours per day, three days per week)
• Residential Treatment (rehabilitation services provided while living on the premises)
• Narcotic Replacement Therapy (such as methadone)

Some counties offer more treatment and recovery services. Tell your doctors about your condition so they can refer you to the right treatment. You may also refer yourself to your nearest local treatment agency. Or call the Substance Use Disorder non-emergency treatment referral line at 1-800-879-2772.

If you have mental illness or emotional needs that your regular doctor cannot treat, specialty mental health services are available. A Mental Health Plan (MHP) provides specialty mental health services. Each county has an MHP.

Specialty mental health services may include, but are not limited to, individual and group therapy, medication services, crisis services, case management, residential and hospital services, and specialized services to help children and youth.

To find out more about specialty mental health services, or to get these services, call your county MHP. Your MHP will determine if you qualify for specialty mental health services. You can get the MHP’s telephone number from the Office of the Ombudsman at 1-888-452-8609 or visit Medi-Cal Specialty Mental Health Services.

If you or your child are under 21 years old, Medi-Cal covers preventive services, such as regular health check-ups and screenings. Regular checkups and screenings look for any problems with your medical, dental, vision, hearing, and mental health, and any substance use disorders. You can also get vaccinations to keep you healthy. Medi-Cal covers screening services any time there is a need for them, even if it is not during your regular check-up. All of these services are at no cost to you.

Checkups and screenings are important to help your health care provider identify problems early. When a problem is found during a check-up or screening, Medi-Cal covers the services needed to fix or improve any physical or mental health condition or illness. You can get the diagnostic and treatment services your doctor, other health care provider, dentist, county Child Health and Disability Prevention program (CHDP), or county mental or behavioral health provider says you need to get better. EPSDT covers these services at no cost to you.

Your provider will also tell you when to come back for the next health check-up, screening, or medical appointment. If you have questions about scheduling a medical visit or how to get help with transportation to the medical visit, Medi-Cal can help. Call your Medi-Cal Managed Care Health Plan (MCP). If you are not in an MCP, you can call your doctor or other provider or visit Transportation Services.

For more information about EPSDT you may call 1-800-541-5555, visit Medi-Cal for Kids & Teens, or contact your county CHDP Program, or your MCP. To learn more about EPSDT Specialty Mental Health or Substance Use Disorder services, contact your county mental or behavioral health department.

Medi-Cal can help with rides to medical, mental health, substance use, or dental appointments when those appointments are covered by Medi-Cal. The rides can be either nonmedical transportation (NMT) or non-emergency medical transportation (NEMT). You can also use NMT if you need to pick up prescriptions or medical supplies or equipment.

If you can travel by car, bus, train, or taxi, but do not have a ride to your appointment, NMT can be arranged.

If you are enrolled in a health plan, call your Member Services for information on how to get NMT services.

If you have Fee-for-Service, you can do the following:

• Call your county Medi-Cal office to see if they can help you get an NMT ride.
• To set up a ride, you should first call your Fee-for-Service medical provider and ask about a transportation provider in your area. Or, you can contact one of the approved NMT providers in your area.

If you need a special, medical vehicle to get to your appointment, let your health care provider know. If you are in a health plan, you can also contact your plan to set up your transportation. If you are in Fee-for-Service, call your health care provider. The plan or provider can order NEMT such as a wheelchair van, a litter van, an ambulance, or air transport.

Be sure to ask for a ride as soon as you can before an appointment. If you have frequent appointments, your health care provider or health plan can request transportation to cover future appointments.

More information about rides arranged by approved NMT providers.

The Working Disabled Program gives Medi-Cal to adults with disabilities who have higher income than most Medi-Cal recipients. If you have earned disability income through Social Security or your former job, you may qualify. The program requires a low monthly premium, ranging from $20 to $250 depending on your income. To qualify, you must:

• Meet the Social Security definition of disability, have gotten disability income, and now be earning some money through work
• Meet program income rules for earned and unearned income
• Meet other program rules

The Breast and Cervical Cancer Treatment Program gives cancer treatment and related services to low-income California residents who qualify. They must be screened and/or enrolled by the Cancer Detection Program, Every Woman Counts, or by the Family Planning, Access, Care and Treatment programs. To qualify, you must have income under the limit and need treatment for breast or cervical cancer. To learn more, call 1-800-824-0088 or email BCCTP@dhcs.ca.gov.

The CCS program gives diagnostic and treatment services, medical case management, and physical and occupational therapy services to children under age 21 who have CCS-eligible medical conditions.

CCS-eligible medical conditions are those that are physically disabling or require medical, surgical or rehabilitative services. Services authorized by the CCS program to treat a Medi-Cal enrolled child’s CCS-eligible medical condition are not services that most health plan’s cover. The Medi-Cal health plan still provides primary care and preventive health services not related to the CCS-eligible medical condition.

To apply for CCS, contact your local county CCS office. To learn more, visit the California Children's Services webpage or call 1-916-552-9105.

You can apply for confidential services if you are under age 21. To qualify, you must be:

• Unmarried and living with your parents, or
• Your parent must be financially responsible for you, such as college students

You do not need parental consent to apply for or get coverage. Services include family planning and pregnancy care, and treatment for drug or alcohol abuse, sexually transmitted diseases, sexual assault, and mental health.

If you were in foster care on your 18th birthday or later, you may qualify for free Medi-Cal. Coverage may last until your 26th birthday. Income does not matter. You do not need to fill out a full Medi-Cal application or give income or tax information when you apply. For coverage right away, contact your local county office.

GHPP gives medical and administrative case management and pays for medically-necessary services for persons who live in California, are over age 21, and have GHPP-eligible medical conditions. GHPP-eligible conditions are inherited conditions like hemophilia, cystic fibrosis, Phenylketonuria, and sickle cell disease that have major health effects. GHPP uses a system of Special Care Centers (SCCs). SCCs give comprehensive, coordinated health care to clients with specific eligible conditions. If the service is not in the health plan’s covered benefits, GHPP authorizes yearly SCC evaluations for Medi-Cal enrolled adults with a GHPP-eligible medical condition.

To apply for GHPP, complete an application. Fax it to 1-800-440-5318. To learn more, call 1-916-552-9105 or go to the Genetically Handicapped Persons Program webpage.

Medi-Cal allows certain eligible seniors and persons with disabilities to get treatment at home or in a community setting instead of in a nursing home or other institution. Home and Community-Based Services include but are not limited to case management (supports and service coordination), adult day health services, habilitation (day and residential), homemaker, home health aide, nutritional services, nursing services, personal care, and respite care. You must qualify for full-scope Medi-Cal and meet all program rules. To learn more, call DHCS, Integrated Systems of Care Division at 1-916-552-9105.

IHSS helps pay for services so you can remain safely in your own home. If you qualify for Medi-Cal, you may also qualify for IHSS. If you do not qualify for Medi-Cal, you may still qualify for IHSS if you meet other eligibility criteria. If you have Medi-Cal with no SOC, it will pay for all your IHSS services. If you have Medi-Cal with a SOC, you must meet your Medi-Cal SOC before any IHSS services are paid. To qualify, you must be at least one of the following:

• Age 65 and older
• Blind
• Disabled (including disabled children)
• Have a chronic, disabling condition that causes functional impairment expected to last at least 12 consecutive months or expected to result in death within 12 months

IHSS can authorize services such as:

• Domestic services such as washing kitchen counters or cleaning the bathroom
• Preparation of meals
• Laundry
• Shopping for food
• Personal care services
• Accompaniment to medical appointments
• Protective supervision for people who are mentally ill or mentally impaired and cannot remain safely in their home without supervision
• Paramedical services

To learn more, go to the In-Home Supportive Services (IHSS) Program webpage.

MCAP gives low-cost comprehensive health insurance coverage to pregnant individuals. MCAP has no copayments or deductibles for its covered services. The total cost for MCAP is 1.5% of your Modified Adjusted Gross Income. For example, if your income is $50,000 per year, your cost would be $750 for coverage. You can pay all at once or in monthly installments over 12 months. If you are pregnant and in Covered California coverage, you may be able to switch to MCAP. Babies born to individuals enrolled in MCAP qualify for the Medi-Cal Access Infant Program or for Medi-Cal. To qualify for MCAP, you must be:

• A California resident
• Not enrolled in no-cost Medi-Cal or Medicare Part A and Part B at time of application
• Not covered by any other health insurance plan
• Within the program income guidelines

Learn more about MCAP online or call 1-800-433-2611.

If you have unpaid medical or dental bills when you apply for Medi-Cal, you can ask for retroactive Medi-Cal. Retroactive Medi-Cal may help pay medical or dental bills in any of the three months before the application date.

For example, if you applied for Medi-Cal in April, you may be able to get help with bills for medical or dental services you got in January, February and March.

To get retroactive Medi-Cal you must:

• Qualify for Medi-Cal in the month you got the medical services
• Have received medical or dental services that Medi-Cal covers
• Ask for it within one year of the month in which you received the covered services
• You must contact your local county office to request retroactive Medi-Cal

For example, if you were treated for a broken arm in January 2017 and applied for Medi-Cal in April 2017, you would have to request retroactive Medi-Cal by no later than January 2018 to pay the medical bills.

If you already paid for medical or dental service you got during the three months of the retroactive period, Medi-Cal may also help you get paid back. You must submit your claim within one year of the date of service, or within 90 days after approval of your Medi-Cal eligibility, whichever is longer.

To file a claim, you must call or write to:

For Medical, Mental Health, Substance Use Disorder, and In-Home Support Services Claims:

For Dental Claims:

To qualify for Medi-Cal, you must live in the state of California and meet certain rules. You must give income and tax filing status information for everyone who is in your family and is on your tax return. You also may need to give information about your property.

You do not have to file taxes to qualify for Medi-Cal. For questions about tax filing, talk to the Internal Revenue Service (IRS) or a tax professional.

All individuals who apply for Medi-Cal must give their Social Security Number (SSN) if they have one. Every person who asks for Medi-Cal must give information about his or her immigration status. Immigration status given as part of the Medi-Cal application is confidential. The United States Citizenship and Immigration Services cannot use it for immigration enforcement unless you are committing fraud.

Adults age 19 or older may qualify for limited Medi-Cal benefits even if they do not have a Social Security Number (SSN) or cannot prove their immigration status. These benefits cover emergency, pregnancy-related and long-term care services.

You can apply for Medi-Cal for your child even if you do not qualify for full coverage.

In California, immigration status does not affect Medi-Cal benefits for children under age 19. Children may qualify for full Medi-Cal benefits, regardless of immigration status.

To learn more about Medi-Cal program rules, read the Qualify Comparison.

Asset limits will return in 2026.

• Through December 31, 2025, Medi-Cal eligibility is based on income only.
• You will not be asked about your assets.
• You do not need to report any assets when you apply for or renew Medi-Cal during this time.

• If you are age 65 or older, have a disability, or need long-term care, Medi-Cal will look at both your income and assets when you apply for or renew your coverage.
• The asset limit is $130,000 for one person. For each additional household member, the limit increases by $65,000, up to 10 members can be in a household
• If your assets are above the limit, you may not qualify for Medi-Cal unless you lower them. Talk to your local county Medi-Cal office to learn more about your options.

NOTE: Medi-Cal’s uses asset limits to help decide if you qualify for coverage. These limits are not the same as the rules for estate recovery. To learn more, visit the Estate Recovery webpage.

Assets

• You are not required to report assets for Medi-Cal applications or renewals submitted through 2025.
• Starting January 1, 2026, the following Medi-Cal members and new applicants will need to report asset information:
  • Age (older adults, 65+ years of age)
  • Disability (physical, mental, or developmental)
  • Long-term care needs
• Assets include:
• Bank accounts
• Cash
• Property
• Vehicles
• Some assets don’t count, like the home you live in, one vehicle, household items, and certain savings, like retirement accounts.

Income

• Income rules are not changing. Medi-Cal still considers:
• Wages and other income
• Income from property may include: 
• Rent
• Income from property you own (like rent or lease payments)

I Already Have Medi-Cal

• You do not need to report assets during your 2025 renewal.
• Starting in 2026, certain members’ assets will be reviewed during renewal.
• Tools and information will be provided to help you report correctly and stay covered.

Enrollment Freeze for Undocumented Members 19+

Starting January 1, 2026, Medi-Cal will freeze new enrollments for certain adults who are undocumented and do not have a satisfactory immigration status for federal full scope Medi-Cal. This group will no longer be able to newly enroll in full scope Medi-Cal, even if they qualified before under state-funded programs.

WHO:

Californians aged 19 and older, who are not pregnant, who are undocumented, and who qualified for full scope Medi-Cal because of the state-funded Adult Expansions.

KEY INFORMATION:

• If you are already enrolled in full scope Medi-Cal, you will stay covered no matter your immigration status as long as you complete your annual renewal. Make sure to renew and use your benefits!
• If you are part of this group and lose your coverage, you won’t be able to sign up again—except for emergency and pregnancy care.
• If your coverage stops because of a late renewal or missing paperwork, you will have 90 days to fix it and stay enrolled.
• Income-eligible children (0-18) and pregnant people can enroll in full scope Medi-Cal, no matter their immigration status. Coverage is for the entire pregnancy and one year after the pregnancy ends.

Dental Coverage

Starting July 1, 2026, dental benefits will no longer be provided to adult Medi-Cal members who do not have satisfactory immigration status.

WHO:

Californians aged 19 and older who do not have a satisfactory immigration status, including, but not limited to:

• Green card holders not exempt from the five-year waiting period, who have had their permanent resident status for less than five years.
• PRUCOL (e.g., with temporary protected status or refugee status).
• People with no immigration status, but who currently qualify under past Medi-Cal expansions.
• People enrolled through a trafficking or crime victim assistance program.
• Lawfully present immigrants who are older than age 20 and not pregnant.

KEY INFORMATION:

• Emergency dental care (such as treatment for severe pain or infection and tooth extractions) will still be covered for everyone, no matter their immigration status.
• If you are pregnant and do not have a satisfactory immigration status, you will continue to receive full dental benefits during pregnancy and up to one year after the pregnancy ends.

Monthly Premiums

Starting July 1, 2027, certain adult Medi-Cal members who do not have a satisfactory immigration status must pay $30 per month to keep full scope Medi-Cal.

WHO:

Californians aged 19-59, who are not pregnant, and who do not have a satisfactory immigration status, including but not limited to:

• Green card holders subject to the five-year waiting period, who have had their permanent resident status for less than five years.
• PRUCOL (e.g., with temporary protected status or refugee status).
• People without federal immigration status who currently qualify under past Medi-Cal expansions.
• People enrolled through a trafficking or crime victim assistance program.
• Lawfully present immigrants who are older than age 20 and not pregnant.

KEY INFORMATION:

• Full scope Medi-Cal coverage for this group includes doctor visits and preventive care, hospital and emergency services, prescription drugs, mental health and substance use disorder treatment, vision care, immunizations, and reproductive health services.
• If you are part of this group and do not pay your premium, your coverage will be reduced to emergency and pregnancy-related services.

The U.S. government does not consider getting health care, food, and housing benefits as part of the public charge rule.

Read more about public charge.

When you apply for Medi-Cal, your personal information is kept private. The state only uses your information to find out if you qualify. The federal government funds some of Medi-Cal, and the state must share some of your information with the US Centers for Medicare & Medicaid Services, a federal agency within the United States Department of Health and Human Services. Federal laws and policies provide some protections of people’s personal information.

Here are examples of information you may be asked to provide when you apply for Medi-Cal. Contact your local Medi-Cal office if you do not have these documents.

Identity

• Copy of driver’s license or photo ID
• Social Security Number (actual card)
• A copy of immigration documentation or card

You only need to provide proof of identity:

• When you first apply
• If you change your name
• For new household members, like a spouse or new baby

Physical/Mailing Address

You do not need to provide proof that you live in California. You only need to provide the address where you live and/or get mail.

You only need to certify that you live in California:

• When you first apply
• When you move

Income

Have a job

• A copy of your most recent pay stub showing:
• Gross income
• Pay period
• Date received
• Hours worked
• A copy of your most recent 1040 tax form, showing annual income information
• A statement from your employer about income received

Work for myself

• A copy of Schedule C of the most recent tax return
• A profit and loss statement for the last three months

Get Social Security or veteran’s benefits

• A copy of paid benefits stub or award letter

Get unemployment or disability benefits

• A copy of paid benefits stubs
• A letter that shows what you earned before deductions

Deductions

Provide a copy of checks or receipts if you pay for:

• Childcare
• Child support
• Alimony
• Health insurance

Self-Attestation

You may self-attest if you:

• Do not have proof of income
• Receive cash income

Your local county Medi-Cal office can tell you how.

It may take up to 45 days to process your Medi-Cal application. If you apply for Medi-Cal based on disability, it may take up to 90 days. Your local county office or Covered California will send you an eligibility decision letter. The letter is called a “Notice of Action.” If you do not get a letter within the 45 or 90 days, you may ask for a State Fair Hearing. You may also ask for a hearing if you disagree with the decision.

You can apply for Medi-Cal at any time of the year online, in person, by mail, or phone.

Medi-Cal covers most medically necessary care. This includes doctor and dentist appointments, prescription drugs, vision care, family planning, mental health care, and drug or alcohol treatment. Medi-Cal also covers transportation to these services.

Once you are approved, you can use your Medi-Cal benefits right away. New beneficiaries approved for Medi-Cal get a Medi-Cal Benefits Identification Card (BIC). Your health care and dental providers need your BIC to provide services and to bill Medi-Cal. New beneficiaries and those asking for replacement cards get the new BIC design showing the California poppy. Both BIC designs shown here are valid:

Please contact your local county office if:

• You did not get your BIC
• Your BIC is lost
• Your BIC has wrong information
• Your BIC is stolen

Once you are sent a new BIC, you cannot use your old BIC.

Most people who are in Medi-Cal see a doctor through a Medi-Cal managed care plan. The plans are like the health plans people have with private insurance. Read more about managed care plans.

It may take a few weeks to assign your Medi-Cal managed care plan. When you first sign up for Medi-Cal, or if you have special situations, you may need to see the doctor through Fee-for-Service Medi-Cal.

Fee-for-Service is a way Medi-Cal pays doctors and other care providers. When you first sign up for Medi-Cal, you will get your benefits through Fee-for-Service Medi-Cal until you are enrolled in a managed care health plan.

Before you get medical or dental services, ask if the provider accepts Medi-Cal Fee-for-Service payments. The provider has a right to refuse to take Medi-Cal patients. If you do not tell the provider you have Medi-Cal, you may have to pay for the medical or dental service yourself.

Your provider uses your BIC to make sure you have Medi-Cal. Your provider will know if Medi-Cal will pay for a medical or dental treatment. Sometimes you may have to pay a “co-payment” for a treatment. You may have to pay $1 each time you get a medical or dental service or prescribed medicine. You may have to pay $5 if you go to a hospital emergency room when you do not need an emergency service. Those beneficiaries enrolled in a managed care plan do not have to pay co-payments.

There are some services Medi-Cal must approve before you may get them.

Some Non-MAGI Medi-Cal programs require you to pay a SOC. The Notice of Action you get after your Medi-Cal approval will tell you if you have a SOC.

It will also tell the amount of the SOC. Your SOC is the amount you must pay or promise to pay to the provider for health or dental care before Medi-Cal starts to pay.

The SOC amount resets each month. You only need to pay your SOC in months when you get health and/or dental care services. The SOC amount is owed to the health or dental care provider. It is not owed to Medi-Cal or the State. Providers may allow you to pay for the services later instead of all at once. In some counties, if you have a SOC you cannot enroll in a managed care plan.

If you pay for health care services from someone who does not accept Medi-Cal, you may count those payments toward your SOC. You must take the receipts from those health care expenses to your local county office. They will credit that amount to your SOC.

You may be able to lower a future month’s SOC if you have unpaid medical bills. Ask your local county office to see if your bills qualify.

Qualifying for Medi-Cal

You may be able to get Medi-Cal even if you have health insurance from your job. If you qualify, Medi-Cal helps pay for things that your insurance doesn’t cover. Under federal law, your private health insurance must be billed first before Medi-Cal.

Report Other Health Coverage

If you have Medi-Cal, you must tell us and your doctor if you also have health insurance from your job. Not doing this is a crime.

Online
Report Other Health Coverage

Phone
1-800-541-5555 (toll-free)
1-916-636-1980 (outside California)
1-800-430-7077 (TTY)

When you travel outside California, take your BIC or proof that you are enrolled in a Medi-Cal health care plan. Medi-Cal can help in some cases, such as an emergency due to accident, injury or severe illness. Except for emergencies, your managed care plan must approve any out-of-state medical services before you get the service. If the provider will not accept Medicaid, you will have to pay medical costs for services you get outside of California. Remember: there may be many providers involved in emergency care. For example, the doctor you see may accept Medicaid but the x-ray department may not. Work with your managed care plan to limit what you have to pay. The provider should first make sure you qualify by calling 1-916-636-1960.

If you live near the California state line and get medical service in the other state, some of these rules do not apply. To learn more, contact your Medi-Cal managed care plan.

If you are moving to a new county in California, you also need to tell the county you live in or the county you are moving to. This is to make sure you keep getting Medi-Cal benefits. You should tell your local county office within 10 days of moving to a new county.

You will not get Medi-Cal if you move out of California. You may apply for Medicaid in the state you move to.

The Medi-Cal Managed Care Office of the Ombudsman helps solve problems from a neutral standpoint. They make sure you get all necessary required covered services.

The Office of the Ombudsman:

• Helps solve problems between Medi-Cal managed care members and managed care plans without taking sides
• Helps solve problems between Medi-Cal beneficiaries and county mental health plans without taking sides
• Investigates member complaints about managed care plans and county mental health plans
• Helps members with urgent enrollment and disenrollment problems
• Helps Medi-Cal beneficiaries access Medi-Cal specialty mental health services
• Offers information and referrals
• Identifies ways to make the Medi-Cal managed care program more effective
• Educates members on how to navigate the Medi-Cal managed care and specialty mental health system

To learn more about the Office of the Ombudsman, you can call: 1-888-452-8609 or go to the Office of the Ombudsman webpage.

Medi-Cal Managed Care is an organized system to help you get high-quality care and stay healthy.

Medi-Cal Managed Care health plans help you find doctors, pharmacies and health education programs.

Most people must enroll in a managed care plan, unless you meet certain criteria or qualify for an exemption. Your health plan options depend on the county you live in. If your county has multiple health plans, you will need to choose the one that fits your and your family’s needs.

Every Medi-Cal managed care plan within each county has the same services. You can get the directory of managed care plans at the Medi-Cal Managed Care Health Care Options website. You can choose a doctor who works with your plan to be your primary care physician. Or your plan can pick a primary care doctor on your behalf. You may choose any Medi-Cal family planning provider of your choice, including one outside of your plan. Contact your managed care plan to learn more.

Managed care health plans also offer:

• Care coordination
• Referrals to specialists
• 24-hour nurse advice telephone services
• Customer service centers

Medi-Cal must approve some services before you may get them. The provider will know when you need prior approval. Most doctors’ services and most clinic visits are not limited. They do not need approval. Talk with your doctor about your treatment plan and appointments.

If you are in a county with more than one plan option, you must choose a health plan within 30 days of Medi-Cal approval. You will get an information packet in the mail. It will tell you the health plan(s) available in your county. The packet will also tell you how to enroll in the managed care plan you choose. If you do not choose a plan within 30 days of getting your Medi-Cal approval, the State will choose a plan for you.

Please wait for your health plan information packet in the mail.

If you live in San Benito County, there is only one health plan. You may enroll in this health plan. Or you may choose to stay in Fee-for-Service Medi-Cal.

If your county has more than one health plan, you will need to choose the one that fits your and your family’s needs.

Change

When your county has more than one plan, you can call Health Care Options if you want to change your managed care health plan.

Disenroll

Most Medi-Cal beneficiaries must enroll in a Medi-Cal managed care plan. If you enrolled in a health care plan by choice, you may disenroll at any time. To disenroll, call Health Care Options at: 1-800-430-4263.

Exemptions

If you are getting treatment now from a Fee-for-Service Medi-Cal provider, you may qualify for a temporary exemption from mandatory enrollment in a Medi-Cal managed care plan. The Fee-for-Service provider cannot be part of a Medi-Cal managed care plan in your county. The provider must be treating you for a complex condition that could get worse if you have to change providers.

Ask your provider if he or she is part of a Medi-Cal managed care plan in your county. If your provider is not part of a Medi-Cal managed care plan in your county, have your provider fill out a form with you to ask for an exemption from enrolling in a Medi-Cal managed care plan.

Your provider will need to sign the form, attach required proof, and mail or fax the form to Health Care Options. They will review it and decide whether you qualify for a temporary exemption from enrollment in a Medi-Cal managed care plan. Download the form and instructions.

If you have questions, call 1-800-430-4263.

Many people who are 65 or older or who have disabilities qualify for both Medi-Cal and Medicare.

If you qualify for both programs, you will get most of your medical services and prescription drugs through Medicare. Medi-Cal provides long-term services and supports such as nursing home care and home and community-based services.

Medi-Cal covers some benefits that Medicare does not cover.

Medi-Cal may also pay your Medicare premiums.

The Medicare Premium Payment Program, also called Medicare Buy-In, allows Medi-Cal to pay Medicare Part A (Hospital Insurance) and/or Part B (Medical Insurance) premiums for Medi-Cal members and others who qualify for certain Medi-Cal programs.

Medicare Savings Programs may pay Medicare Part A and Medicare Part B deductibles, co-insurance and co-payments if you meet certain conditions.

When you apply for Medi-Cal, your county will evaluate you for this program. Some people who do not qualify for full-scope Medi-Cal benefits may still qualify for MSP.

If eligible to MSP you will not have to pay any co-insurance or deductibles. If you get a bill from your Medicare provider, contact your Medi-Cal managed care plan or call 1-800-MEDICARE.

You can use any Medicare provider, even if that provider doesn’t take Medi-Cal or isn’t part of your Medi-Cal managed care plan. Some Medicare providers may not accept you as a patient.

To keep your Medi-Cal benefits, you must renew at least once a year. If your local county office cannot renew your Medi-Cal coverage using electronic sources, they will send you a renewal form. You will need to give information that is new or has changed. You will also need to give your most current information. You can return your information online, in person, by phone, or mail. If you mail or return your renewal form in person, it must be signed.

If you do not give the needed information by the due date, your Medi-Cal benefits will end. Your local county office will send you a Notice of Action in the mail. You have 90 days to give your local county office all the missing information without having to re-apply. If you give the missing information within 90 days and still qualify for Medi-Cal, your local county office will reinstate your Medi-Cal with no gaps in coverage.

You must report any household changes within 10 days to your local county office. You can report changes in person, online, by phone, email or fax. Changes can affect your Medi-Cal eligibility.

You must report if you:

• Get married or divorced
• Have a child, adopt or place a child for adoption
• Have a change in income or property (if applicable)
• Get any other health coverage including through a job or a program such as Medicare
• Move, or have a change in who is living in your home
• Have a change in disability status
• Have a change in tax filing status, including change in tax dependents
• Have a change in citizenship or immigration status
• Are incarcerated (jail, prison, etc.) or released from incarceration
• Have a change in American Indian or Alaska Native status or change your tribal status
• Change your name, date of birth or SSN
• Have any other changes that may affect your income or household size

If you move to another California county, you can have your Medi-Cal case moved to the new county. This is called an Inter-County Transfer (ICT). You must report your change of address to either county within 10 days from the change. You can report your change of address online, in person, by phone, email, or fax. Your managed care plan coverage in your old county will end on the last day of the month. You will need to enroll in a managed care plan in your new county.

When you leave the county temporarily, your Medi-Cal will not transfer. This includes a child going to college or when you take care of a sick relative. Contact your local county office to report the household member’s temporary address change to a new county. The local county office will update the address so the household member can enroll in a health plan in the new county.

A beneficiary must always present proof of Medi-Cal coverage to providers before getting services. If you are getting treatment from more than one doctor or dentist, you should tell each doctor or dentist about the other doctor or dentist providing your care.

It is your responsibility not to abuse or improperly use your Medi-Cal benefits. It is a crime to:

• Let other people use your Medi-Cal benefits
• Get drugs through false statements to a provider
• Sell or lend your BIC to any person or give your BIC to anyone other than your service providers as required under Medi-Cal guidelines

Misuse of BIC/Medi-Cal benefits is a crime. It could result in negative actions to your case or criminal prosecution. If you suspect Medi-Cal fraud, waste or abuse, make a confidential report by calling: 1-800-822-6222 or visit the DHCS Fraud webpage.

If you suffer an injury, you may use your Medi-Cal to get medical services. If you file an insurance claim or sue someone for damages because of your injury, you must notify the Medi-Cal Personal Injury (PI) program within 30 days of filing your claim or action. You must tell both your local county office and the PI program.

To notify the Medi-Cal PI program, please complete the “Personal Injury Notification (New Case)” form.

If you hire a lawyer to represent you for your claim or lawsuit, your lawyer is responsible for notifying the Medi-Cal PI program and giving a letter of authorization. This authorization allows Medi-Cal staff to contact your lawyer and discuss your personal injury case. Medi-Cal does not provide representation or attorney referrals. Staff can offer information that can help the lawyer through the process.

The Medi-Cal program must seek repayment from the estates of certain Medi-Cal members who have died. Repayment is limited to payments made, including managed care premiums, for nursing facility services, home and community based services, and related hospital and prescription drug services when the beneficiary:

• Was an inpatient in a nursing facility, or
• Received home and community based services on or after his or her 55th birthday

If a deceased member does not leave an estate subject to probate or owns nothing when they die, nothing will be owed.

To learn more, go to the Estate Recovery Program webpage or call 1-916-650-0590

Health Care Services and Benefits

You have the right to ask for an appeal if you disagree with the denial of a health care service or benefit.

If you are in a Medi-Cal managed care plan and you get a Notice of Action letter telling you that a health care service or benefit is denied, you have the right to ask for an appeal.

You must file an appeal with your plan within 60 days of the date on the Notice of Action. After you file your appeal, the plan will send you a decision within 30 days. If you do not get a decision within 30 days or are not happy with the plan’s decision, you can then ask for a State Fair Hearing. A judge will review your case. You must first file an appeal with your plan before you can ask for a State Fair Hearing. You must ask for a State Fair Hearing within 120 days of the date of the plan’s written appeal decision.

If you are in Fee-for-Service Medi-Cal and you get a Notice of Action letter telling you that a health service or benefit has been denied, you have the right to ask for a State Fair Hearing right away. You must ask for a State Fair Hearing within 90 days of the date on the Notice of Action.

You also have the right to ask for a State Fair Hearing if you disagree with what is happening with your Medi-Cal application or eligibility. This can be when:

• You do not agree with a county or State action on your Medi-Cal application
• The county does not give you a decision about your Medi-Cal application within 45 or 90 days
• Your Medi-Cal eligibility or Share of Cost changes

Eligibility Decisions

If you get a Notice of Action letter teling you about an eligibility decision that you disagree with, you can talk to your county eligibility worker and/or ask for a State Fair Hearing. If you cannot solve your disagreement through the county, you must request a State Fair Hearing within 90 days of the date on the Notice of Action. You can ask for a State Fair Hearing by contacting your local county office. You can also call or write to:

File a hearing request online.

If you believe you have been unlawfuly discriminated against on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can make a complaint to the DHCS Office of Civil Rights.

The State will tell you it got your hearing request. You will get a notice of the time, date and place of your hearing. A hearing representative will review your case and try to resolve your issue. If the county/State offers you an agreement to solve your issue, you will get it in writing.

You can give permission in writing for a friend, family member or advocate to help you at the hearing. If you cannot fuly solve your issue with the county or State, you or your representative must attend the State Fair Hearing. Your hearing can be in person or by phone. A judge who does not work for the county or Medi-Cal program will hear your case.

You have the right to free language help. List your language on your hearing request. Or tell the hearing representative you would like a free interpreter. You cannot use family or friends to interpret for you at the hearing.

If you have a disability and need reasonable accommodations to fully take part in the Fair Hearing process, you may call 1-800-743-8525 (TTY 1-800-952-8349). You can also send an email to SHDCSU@DSS.ca.gov.