​​​​​Medi-Cal Managed Care – Frequently Asked Questions​

• Certain home and community-based services 
• Most Medi-Cal pharmacy services 
  
• Substance use disorder (SUD) treatment services 
• Dental services 

If you have Medicare, your Medi-Cal health plan can also give you more benefits that Medicare may not cover and can help you access Medicare services such as: 

• Transportation to medical appointments 
• Durable medical equipment 
  
• Medical supplies 
• Community Supports 

​​For more information about Medi-Cal health benefits, go to: Medi-Cal Health Benefits.

4. Who must join a Medi-Cal health plan?

Medi-Cal members are “mandatory" if they get CalWORKs benefits (cash aid, CalFresh), Medi-Cal only with no share of cost*, have both Medi-Cal and Medicare, and/or have Other Health Coverage (OHC). This means they must join a Medi-Cal health plan.

*Members who receive long-term care services and have a share of cost must enroll in a Medi-Cal health plan.

For a list of Medi-Cal health plans in your county, go to Health Plan Directory webpage.

5. Who does not have to join a Medi-Cal health?

• Are an American Indian/Alaska Native,
• Are a member who gets assistance under foster care, the Adoption Assistance Program, or Child Protective Services,
• Live in a California Veteran's Home,
• Already have an approved medical exemption from the requirement to join a Medi-Cal health plan, or
• Get a medical exemption from the requirement to join a Medi-Cal health plan.

6. What if I am an American Indian or Alaska Native Member?

If you are an American Indian or Alaska Native member enrolled in a Medi-Cal health plan, you may get services from an Indian Health Care Provider of your choice. If you have questions about your benefits, call your Medi-Cal health plan or the Medi-Cal Ombudsman at (888) 452-8609. To learn more and to find an Indian Health Care Provider near you, go to Indian Health Care Programs (IHCP) locato​r.​ 

7. Do I have a choice in my Medi-Cal health plan?

To find out if you have more than one Medi-Cal health plan choice in your county, go to the Health Plan Directory webpage. 

8. How do I choose a Medi-Cal health plan?

Your Medi-Cal health plan choices depend on two things: 

1. The county you live in, and 
2. If you are in a Medicare Advantage (MA) plan 

9. Where can I find more information about Medi-Medi Plans for people with both Medicare and Medi-Cal?

For people with both Medicare and Medi-Cal, Medi-Medi Plans are available in certain counties for voluntary enrollment. Medi-Medi Plans are a type of Medicare Advantage plan in California that are only available to dual eligible members and provide integrated care. 

Medi-Cal has a Medi-Cal matching plan policy in certain counties. This means that if you join a Medicare Advantage plan and there is a Medi-Cal plan that matches with that plan, you will be automatically enrolled in that matching Medi-Cal plan. This policy does not change or affect your choice of a Medicare plan.

For a list of Medi-Medi Plans by county, and to find out how to enroll, visit the Medi-Medi Plan directory webpage.

10. Can I enroll in Kaiser Permanente?

You may join Kaiser Permanente if you live in one of the counties that has Kaiser Permanente as a Medi-Cal health plan option. 
You also have to meet one of these requirements: 

• You were a Kaiser Permanente member in the last 12 months, or 
• You are an immediate family member of a current Kaiser Permanente member (family linkage),
• You are a foster child, or former foster child, or
• You have both Medicare and Medi-Cal (dual eligible).  

To learn how to enroll in Kaiser Permanente, call Medi-Cal HCO Monday – Friday, 8 a.m. to 6 p.m. at (800) 430-4263 (TTY: (800) 430-7077). 

11. Can I enroll in the Program of All-Inclusive Care for Elderly (PACE)?

If you are 55 years old or older and need a higher level of care to live at home, you may qualify to join a PACE plan in your area. 

PACE will coordinate your healthcare, homecare, transportation, and specialty care such as dental care and hearing aids. PACE also offers social centers and senior gyms.

Enrollment in PACE is voluntary. You can disenroll at any time. There is an application process to join PACE. It includes a health assessment. This is to learn about your care needs. The process can take a few weeks. If you have Medi-Cal, there are no other co-pays or deductibles to enroll in PACE. PACE services include, but are not limited to:

• Behavioral health services
• Provider and specialist visits 
• Emergency and urgent care 
• Equipment and medical supplies
• Home health care
• Hospital care and surgeries
• Nursing home care
• Nutritional counseling and prepared meals
• Physical, occupational, and speech therapy 
• Prescription drugs
• Transportation to and from the PACE centers and outside medical appointments 
• Vision and dental services

To find out if PACE is available in your county or to learn more about PACE, go to the CalPACE website. Or call Medi-Cal HCO at (800) 430-4263 (TTY (800) 430-7077 or 711).

12. Can I enroll in a Senior Care Action Network (SCAN) health plan?

SCAN is for members with Medicare. If you have both Medicare and Medi-Cal, you may join SCAN Connections (HMO SNP). It is a specialty health plan, the only one like it in California.

With SCAN Connections, you get all Medicare and Medi-Cal benefits. Plus, you get extra benefits to help you stay healthy. SCAN Connections offers a Personal Assistance Line to help answer benefits or health care questions. Your personal assistant can also help you make providers' appointments. You may also qualify for even more senior services such as in-home and personal care.

To join SCAN Connections, you must:

• Be age 65 or older, 
  
• Live in Los Angeles, Riverside, San Bernardino, or San Diego County, and
  
• Keep your Medicare Parts A and B and Medi-Cal

If you want to stay in FFS Medi-Cal, ask for a medical exemption as soon as you can. In most cases, you cannot get an exemption from managed care enrollment after you have been in a Medi-Cal health plan for 90 days. Your doctor, clinic, or an advocate can help you fill out the form. Your doctor will also need to fill out part of the form. Return the completed form to Medi-Cal HCO. If you are getting treatment now from a FFS Medi-Cal provider, you may qualify for a temporary exemption from mandatory enrollment in a Medi-Cal health plan. The FFS provider cannot be part of a Medi-Cal health plan in your county. The provider must be treating you for a complex condition that could get worse if you have to change providers.

You do not need a medical exemption to keep your Medicare providers. You can continue seeing your Medicare providers even while enrolled in a Medi-Cal health plan.

There are two ways you can ask for a medical exemption:

1. Call Medi-Cal HCO Monday – Friday, 8 a.m. to 6 p.m. at (800) 430-4263 (TTY: (800) 430-7077).
2. Go to Medi-Cal HCO website
   

If your medical exemption is approved, you can stay in FFS Medi-Cal and keep your doctor until the medical exemption ends. 

If you have certain health conditions and want to keep your FFS Medi-Cal provider for more than 12 months, you may be able to ask for a medical exemption extension. You must wait until at least 11 months from your existing medical exemption's start date to ask for an extension. Medi-Cal HCO will tell you when it is 45 days before your medical exemption ends. They will tell you how to ask for an extension. 

If your exemption is denied, you may be able to keep your doctor if you ask your Medi-Cal health for “continuity of care​."  This includes your primary care doctor, specialists, and most therapists. Your Provider and Medi-Cal health plan must come to a mutual agreement to allow you to continue to see your Provider. To find out if you qualify for continuity of care you will need to contact your Medi-Cal health plan. You can find out more information on the continuity of care website.

To learn more about exemptions from joining a Medi-Cal health plan, call Medi-Cal HCO Monday – Friday, 8 a.m. to 6 p.m. at (800) 430-4623 (TTY: (800) 430-7077). Or go to the Medi-Cal HCO​ website.

14. What if I am not happy with my Medi-Cal health plan?

If you are not satisfied with your Medi-Cal health services, you have the right to:

• Change your Medi-Cal health plan
• File a complaint or grievance with your Medi-Cal health plan
• Report the problem to the California Department of Health Care Services State Ombudsman
• Report the problem to the California Department of Managed Health Care Office of Patient Advocacy
• Ask for a State Hearing with an Administrative Law Judge
  

• File your grievance by phone
• Ask to have a grievance form mailed to your home address
• Get a grievance form from your provider
• Send a letter to your Medi-Cal health plan
• Submit a grievance online through your plan's website

If you fill out and mail the form, keep a copy for your records.

Your Medi-Cal health plan will review your grievance and answer within 30 days. If you think waiting 30 days will harm your health or you believe your health is in danger, ask for an “expedited" (fast) grievance. Explain why when you submit the form.

Your Medi-Cal health plan will confirm if your matter is urgent and approve your grievance as expedited. If your expedited grievance or appeal is granted, your Medi-Cal health plan must complete your expedited grievance within 3 days.

If your Medi-Cal health plan does not approve your expedited grievance, they will respond within 30 days.

You may be able to get free legal help from your county's Legal Aid Office by calling (888) 804-3536.

16. What happens if I am enrolled in a Medi-Cal health plan but then lose my Medi-Cal coverage?

If your Medi-Cal ends, you will have a 3-month grace period to re-enroll in Medi-Cal. The grace period starts the last date you were eligible. That date is on your Notice of Action.

If you do not re-enroll by the end of the grace period, you have to apply for Medi-Cal again.

If you call your county Medi-Cal office in the 3-month grace period after Medi-Cal ends, and you qualify for Medi-Cal, you will be re-enrolled. You will stay in your Medi-Cal health plan.

If your Medi-Cal ends, call your county Medi-Cal office as soon as you can. The county eligibility worker will tell you what to do to restart your Medi-Cal. Be sure to answer all county requests so your Medi-Cal restarts and continues without interruption. If you do not re-enroll by the end of the grace period, you must re-apply for Medi-Cal.
Note:

• If you are approved for Medi-Cal and live in a county with more than one Medi-Cal health plan choice, you must choose a Medi-Cal health plan within 30 days. Medi-Cal Health Care Options will mail you a new Medi-Cal Choice form. If you do not choose a Medi-Cal health plan within 30 days, Medi-Cal will choose one for you
• If you are approved for Medi-Cal and live in a county with only one Medi-Cal health plan choice, you will be automatically enrolled in that Medi-Cal health plan.

17. What other services can I get through Medi-Cal?

California Children's Services (CCS) Program

You or your child may qualify for the CCS Program. CCS is a state program for children and youth with certain medical conditions, physical limitations, or chronic health problems. Children and youth up to 21 years old can get health care and services they need. CCS will connect a child or youth with doctors and trained health care people who know how to care for their health care needs. 

A child or youth may qualify for the CCS Program if the child or youth: 

• Is under 21 years old, 
  
• Has a CCS eligible medical condition 
• Is a resident of California, and 
• Has a family income under $40,000 
  

Dental services

• You can get dental services through Medi-Cal. Your dental benefits do not change when you enroll in a Medi-Cal health plan. 
  

• For most counties, you get FFS Medi-Cal dental services through the Medi-Cal Dental Program. You need to go to a dental provider who takes Medi-Cal Dental. To find a dental provider, you can call the Medi-Cal Dental Customer Service Center at (800) 322-6384 (TTY: (800) 735-2922), Monday – Friday, 8 a.m. to 5 p.m. You can also find a dental provider and more about Medi-Cal dental services on the “Smile, California" website.​

• If you live in Sacramento County, you will get services through a Medi-Cal dental plan. To learn more about these plans, call Medi-Cal HCO Monday – Friday, 8 a.m. to 6 p.m. at (800) 430-4263 (TTY: (800) 430-7077).​

• If you live in Los Angeles County, you can get services through the Medi-Cal Dental Program with FFS dental or a Medi-Cal dental plan. To learn more about joining a Medi-Cal dental plan, call Medi-Cal HCO Monday – Friday, 8 a.m. to 6 p.m. at (800) 430-4263 (TTY: (800) 430-7077).

• If you live in San Mateo County, you will get dental services through the Health Plan of San Mateo (HPSM) or FFS dental.
• If you are enrolled in HPSM, you will receive dental services through HPSM. To learn more about HPSM, call member services Monday – Friday, 8 a.m. to 6 p.m. at (800) 750-4776 (TTY: (800) 735-2929). ​

• If you are enrolled in Kaiser Permanente, you will receive dental services through FFS dental. To find a dental provider, you can call the Medi-Cal Dental Customer Service Center at (800) 322-6384 (TTY: (800) 735-2922), Monday – Friday, 8 a.m. to 5 p.m.

In-Home Supportive Services (IHSS) Program

The IHSS program helps pay for services that help you stay safely in your own home. IHSS is an alternative to out-of-home care such as nursing homes or board and care facilities. IHSS can authorize these types of services: 

• Housecleaning 
  
• Meal preparation 
  
• Laundry 
• Grocery shopping 
• Personal care services, such as bowel and bladder care, bathing, grooming, and paramedical services 
• Accompaniment to medical appointments 
• Protective supervision for the mentally impaired 

To apply for IHSS, contact your local county social services agency. To find your local county services agency go to the CDSS website. A county social worker will interview you at your home to find if you qualify for and need IHSS. Based on your ability to safely perform certain tasks for yourself, the social worker will assess the types of services you need and the number of hours the county may authorize for those services. 

If you are approved for IHSS in most counties, you must hire someone (your individual provider) to perform the authorized services. Your county IHSS Public Authority can help connect you with qualified IHSS providers.

​Mental health services

If you need mental health services, talk to your Medi-Cal health plan member services. Or talk to your PCP or your county mental health plan. You may get mental health services through your Medicare or Medi-Cal health plan's network. You may also qualify for specialty mental health services from your county mental health plan. 

Your Medi-Cal health plan and your county mental health plan must help you with your mental health care needs. They must help you find a provider. For your county mental health plan contact information, go to the MHP Contact List webpage. No matter which one you contact, you should get services right away. You do not need a diagnosis to get care. 

Alcohol and substance use disorder treatment services

If you need help with alcohol or other substance use disorder (SUD) treatment services, you can get an assessment from your Medi-Cal health plan. You can also call your county Drug Medi-Cal program for SUD treatment services. To find your local county Drug Medi-Cal program go to the SUD Directories webpage. Or call your Medi-Cal health plan member services for help to get SUD treatment. 

Pharmacy services

Medi-Cal Rx covers prescription drugs that your provider prescribes for you to get from a pharmacy. Your Medi-Cal health plan covers the drugs your provider gives you in person, such as at the doctor's office or clinic. 

To learn more about Medi-Cal Rx prescription drug coverage and pharmacies that take Medi-Cal, go to the Medi-Cal Rx website. Or call the Medi-Cal Rx Customer Service Center at (800) 977-2273 (TTY: State Relay at 711). Have your Medi-Cal Benefits Identification Card (BIC) number ready when you call. You can fill your prescriptions at any Medi-Cal enrolled pharmacy statewide through Medi-Cal Rx. To find one near you, use the Medi-Cal Rx Pharmacy Locator​.

If you qualify for Medicare, Medicare Part D will cover most prescriptions. You must pay any co-pays. Medi-Cal will only pay for a few medications not in your Part D plan.

Transportation

If you do not have a way to get to doctor, clinic, dentist, mental health, or substance use disorder treatment services appointments, or to pick up medicine or for other Medi-Cal covered services, you may qualify for free transportation services. You can get these services, called “Non-Medical Transportation (NMT)" by car, taxi, bus, or other public or private vehicle. NMT is available for appointments covered by your Medi-Cal health plan as well as services covered by Medi-Cal but not through the Medi-Cal health plan, such as substance use disorder treatment services. 

If you cannot use a car, bus, taxi, or other public or private vehicle to get to your appointments due to your health conditions, you may get Non-Emergency Medical Transportation (NEMT) services to your appointments by ambulance, wheelchair van, or litter van. NEMT is for people who cannot use public or private transportation. You will need a prescription from a licensed provider to get NEMT. Your primary care provider, dentist, podiatrist, mental health, or substance use disorder provider can prescribe NEMT. 

Your Medi-Cal health plan can help you schedule your transportation. To ask for a ride, call the Medi-Cal health plan's member services. 

When asking for transportation, you must contact your Medi-Cal health plan as soon as you can before an appointment. If you have many appointments, you can also ask for transportation to those appointments all at once.