Medicaid, instituted in 1965, is a federal/state insurance program for low-income and needy people that provides health coverage for children, many seniors, and/or people who are blind or have other disabilities. The program is jointly funded by the federal government, all fifty states, and the District of Columbia. The Medicaid program in California is called “Medi-Cal.”
The federal government requires each state to cover certain mandatory groups of people in the Medicaid program. These categories include children, pregnant women, very low-income parents, low-income elderly, and people who are blind or disabled.
States have 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 federal criteria are:
- Children under age six with family incomes up to 133% of the federal poverty level.
- Children ages 6-19 (California extends eligibility for children to age 21) with family incomes up to 100% of the federal poverty level.
- Pregnant women with family incomes up to 133% of the federal poverty level.
- Supplemental Security Income (SSI) recipients in most states.
- Recipients of adoption or foster care.
- Certain Medicare beneficiaries.
The Affordable Care Act of 2010 creates a national Medicaid minimum eligibility level of 138% of the federal poverty level ($15,415 for an individual; $26,344 for a family of three in 2012) for nearly all Americans under age 65. This Medicaid eligibility expansion goes into effect on January 1, 2014 and is optional for states, with virtually all of the costs borne by the federal government for the first few years. California has decided to participate in the expansion.
The Medicaid-Medicare Relationship
Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. Beneficiaries who are “dual eligibles” are persons who qualify, in some way, for both Medicare and Medicaid coverage. Medicare covers their acute care services, while Medicaid covers Medicare premiums and cost sharing, and—for those below certain income and asset thresholds—long-term care services, among other services. For persons enrolled in both programs, any services that are covered by Medicare are paid before any payments are made by Medicaid, as Medicaid is always the “payer of last resort.”
Medicaid Dental Benefits
As part of the federal Medicaid program, states are required to provide dental services to enrolled children under the Federal Early Periodic Screening Diagnosis and Treatment Program (EPSDT) up to the age of 19 (to age 21 in California); dental benefits for adults are optional. The dental portion of California’s Medi-Cal program is called Medi-Cal Dental Services and is administered by the California Department of Health 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 Los Angeles County. Mandatory managed care, referred to as Geographic Managed Care (GMC), operates in Sacramento County.
Medi-Cal’s dental benefit program covers a comprehensive package of benefits including diagnostic and preventive services such as examinations and cleanings, restorative services such as fillings, and oral surgery services. Find Beneficiary Services information on the Medi-Cal Dental Services Branch website.
Comprehensive dental coverage for adult Medicaid beneficiaries is optional for states. As of June 30, 2009, in compliance with federal rules, Denti-Cal restricted adult benefits to services provided on an emergency basis to relieve pain and infection. A fuller range of services is available to pregnant women, adult residents of skilled nursing or intermediate care facilities, and Regional Center enrollees.
Child Health and Disability Prevention (CHDP) and Early Periodic Screening, Diagnosis and Treatment (EPSDT)
In California, administration of Medicaid benefits for children younger than 21 is shared between two programs – California’s Child Health and Disability Prevention (CHDP) Program 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 and children up to the age of 21 who are 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/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 educate families about the benefits of prevention, the health services and assistance available, and to help families utilize available health resources.
EPSDT requires early and periodic screening and diagnosis of eligible Medicaid recipients under age 21, and provides treatment to correct or ameliorate eligible conditions. The agency provides “periodic comprehensive child health assessments,” using the CHDP guidelines.
A dental assessment is required at every CHDP visit and physicians are required to make an annual referral to a dentist beginning at age three regardless of whether a dental problem is detected or suspected. Annual dental referrals are recommended beginning at age one. If a CHDP provider cannot provide the dental service(s) needed, he or she must refer the patient to a dentist or refer the patient to a Medicaid agency who will handle the referral.
California’s CHIP Program: Healthy Families
The federal Children’s Health Insurance Program (CHIP) was created in 1997 and is known as “the Healthy Families Program” in California. Healthy Families is jointly funded by the federal and state government and is administered by the California Managed Risk Medical Insurance Board (MRMIB). Healthy Families was created to increase access to affordable, comprehensive, quality health-care coverage, including dental care coverage, for children whose family income exceeds the eligibility for Medi-Cal. Children ages 18 years and younger, in households with an income at or below 250% of the Federal Poverty Line, were eligible for the program.
As part of the implementation of health care reform in California, beginning on January 1, 2013, enrollees in the Healthy Families Program will be transitioned to the Medi-Cal program. The transfer will take place in four phases over 2013, depending on an enrollee’s county of residence. For dental care, children in Sacramento will be automatically assigned to a dental managed care plan, consistent with the Geographic Managed Care program in Sacramento County. In Los Angeles, enrollees with have the option of choosing a dental managed care plan or a dentist in the Denti-Cal (fee-for-service) program. In all other counties, children will be automatically placed into the Denti-Cal program.
California Children’s Services (CCS)
CCS is a statewide program that treats children with certain physical limitations and health conditions. It is managed by the Department of Health Care Services, but administered through counties. The large counties manage their own programs and the smaller counties share the operation of their programs with state regional offices in Sacramento, San Francisco and Los Angeles. CCS 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 one of the following:
- 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
- Has a need for the Medical Therapy Program; or
- Is a Medi-Cal beneficiary with full benefits; or
- Is an enrollee in the Healthy Families Program (until transitioned into the Medi-Cal program in 2013).
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.
Some dental services are available for children in the CCS program, when their dental care needs are associated with their medical care. CCS also covers orthodontics when medically necessary. Claims for dental services are submitted to and processed by the Denti-Cal program. (See Section 9 of the Denti-Cal Provider Handbook.)