California Government Benefits Programs

Medicaid, instituted in 1965, is a federal/state entitlement program that pays for medical assistance for individuals and families with low incomes and resources. It is the largest source of funding for medical and health-related services for America’s most disadvantaged populations.
Within broad federal guidelines, each state administers its own program and:

  • Establishes its own eligibility standards;
  • Determines the type, amount, duration and scope of services;
  • Sets the rate of payment for services.

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:

  • Individuals that meet the requirements for the Aid to Families with Dependent Children (AFDC) Program that were in effect in their state on July 16, 1996.
  • Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL).
  • Pregnant women whose family income is below 133% of the FPL (services limited to those related to pregnancy. In California, this includes periodontal care).
  • Supplemental Security Income (SSI) recipients in most states.
  • Recipients of adoption or foster care.
  • All children born after September 30, 1983 who are under age 19, in families with incomes at or below the FPL.
  • Certain Medicare beneficiaries.

States also have the option of providing Medicaid coverage for other groups, such as low-income adults or people with disabilities.

The Medicaid-Medicare Relationship

Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. 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.”

California’s Medicaid Program

California Medicaid program, Medi-Cal, is the nation’s largest Medicaid program, serving 6.8 million people. In 2009-10, program costs totaled $39 billion, $27 billion of which is paid for by the federal government. California’s program:

  • Insures low-income children, parents, blind, elderly and disabled individuals.
  • Insures 1 in 10 Californians under the age of 65 and 1 in 3 children.
  • Insures children, birth to age 1, from families with income at or below 200%  FPL.
  • Insures children, ages 1-5, from families with income at or below 133% FPL.
  • Insures children, ages 6-20, from families with income at or below 100% FPL.
  • Pays for the care provided to two-thirds of California nursing home residents.

Eligibility

California has several different Medi-Cal programs designed to offer advantages to various populations. Eligibility differs depending upon the program. There are 7 general categories of eligibility requirements:

  • Citizenship status
  • Family assets
  • California residency
  • Institutional status
  • Income
  • Deprivation
  • Eligibility for other public assistance programs

As with federal Medicaid funding requirements, income is only one category for determination of Medi-Cal eligibility; programs consider a wide range of factors to determine net income.

Medicaid Dental Benefits

Dental benefits for children are mandatory under the Federal Early Periodic Screening Diagnosis and Treatment Program (EPSDT); dental benefits for adults are optional.  The dental portion of California’s Medi-Cal program is called Medi-Cal Dental 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, Riverside, and San Bernardino counties, serving approximately 200,000 beneficiaries. Mandatory managed care, referred to as Geographic Managed Care (GMC), operates in Sacramento and San Diego counties.

California’s Medi-Cal Dental Services Program
California established an adult dental program for Medi-Cal beneficiaries when the program began in 1965.  However, since 2000, changes intended to lower program costs and reduce fraud have been made several times to the adult dental benefit portion of California’s Medi-Cal program.

  • SBX1 26 (October 2003) eliminated laboratory processed crowns on posterior teeth for adults, reduced fees for scaling and root planning, and established a four filling threshold for pre-treatment x-ray submission for post-treatment claims.
  • Assembly Bill 131(January 2006) limited dental services to individuals 21 years of age or older to $1,800 per beneficiary for each calendar year.  This limitation carried a sunset date of January 2009 and did not apply to several critical services, including, emergency dental services; services that are federally mandated, including pregnancy-related services; dentures; maxillofacial and complex oral surgery; and services provided in long-term care facilities.
  • Assembly Bill X3 5 (July 1, 2009) eliminated preventive and restorative dental care for adults, effectively reducing the adult dental program to emergency care.

Prior to changes that began in 2003, the Denti-Cal program cost approximately $800,000,000/year; $400,000,000 in general fund dollars and $400,000,000 in federal dollars.  By contrast, Medi-Cal dental expenditures for fiscal year 2009-10 are estimated at $481,675,520 with $ 174,693,990 coming from the State General Fund.

State Children’s Health Insurance Program (CHIP)

The Balanced Budget Act of 1997 created a new children’s health insurance program (CHIP), known in California as Healthy Families. This program gave each state permission to offer health insurance for children, up to age 19, who are not already insured. CHIP is a state administered program and each state sets its own guidelines regarding eligibility and services. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3) reauthorized the Children's Health Insurance Program (CHIP) and finances CHIP through FY 2013.

California’s CHIP Program, Healthy Families

Healthy Families is jointly funded by the federal and state government and administered by the Managed Risk Medical Insurance Board (MRMIB). Healthy Families provides insurance to children of families whose incomes are too high to qualify for Medi-Cal, but are below 250% of the FPL (about $46,325 for a family of 3). The program:

  • Insures ~900,000 California children under the age of 19.
  • Covers a range of medically necessary diagnostic, preventive and treatment services.
  • Pays through managed care plans.
  • Costs between $4 and $24 per child per month, with a maximum of $72 for the family.
  • Uses federal (67%) and state (33%) revenues.

Excludes children who:

  • Have been covered by health insurance during the previous 3 months;
  • Are not U.S. citizens or legal residents.

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 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
    • The child has Healthy Families coverage.

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.

Child Health and Disability Prevention and Early Periodic Screening, Diagnosis and Treatment

Administration of Medicaid benefits for children younger than 21 is shared between two entities – 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 21who 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.
Resources:

Updated May 2011