Children will need to select a Health Plan once determined eligible.
- Once found eligible, most children must enroll in a Medi-Cal managed care plan.
- Children who meet certain criteria and are approved can opt out of Medi-Cal managed care and stay in fee-for-service Medi-Cal. Forms for medical exemption requests are here.
- After being approved for full-scope Medi-Cal, children will receive two mailings:
- A letter explaining Medi-Cal managed care with some FAQs
- Then two days later, a health plan “choice” packet. Copies of the choice packet materials and other materials can be found here.
- Health plan selection process is determined by county. To see the plans in each county here.
- Children who reside in a County Organized Health Systems (COHS) are automatically enrolled in a health plan. Children in all other counties (Non-COHS) receive a Health Care Options packet with information on Medi-Cal Managed Care Plans (MCPs) in their county and their providers.
- COHS counties (22) include: Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Merced, Modoc, Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Trinity, Ventura, and Yolo.
- Children in all other counties (Non-COHS) receive a Health Care Options packet with information on Medical Managed Care Plans (MCPs) in their county and their providers. In a non-COHS counties, families have 30 days to choose a plan. If no plan is selected, DHCS automatically assigns each child a health plan.
- Children who are in a Kaiser Plan must choose to enroll in Kaiser. (See Kaiser’s Frequently Asked Questions document).
- Within a week of enrollment the health plan will mail a “Welcome Packet” to new enrollees.
Expedited plan enrollment
- If a child needs to get into a Medi-Cal health plan immediately and cannot use fee-for-service to see the provider or get the treatment they need, they can ask for expedited enrollment into a Medi-Cal managed care plan.
- Expedited enrollment is only available by phone with the Medi-Cal Managed Care Ombudsman at 888-452-8609.
- County Medi-Cal offices can do an online fillable form with Health Care Options – so if you have a county worker who can vouch for the urgent medical need, ask the worker to fill out the online form to request expedited enrollment.
- When calling Health Care Options, the enrollee should know which Medi-Cal health plan they need and that they need to enroll as soon as possible.
- To know which plan to choose, families should ask their provider which Medi-Cal managed care health plan(s) s/he accepts.
Accessing care before you are in a plan
- If a child does not have an urgent medical need that requires expedited plan enrollment, but needs to medical care before they are enrolled in and covered by a Medi-Cal managed care plan, a child can see a “fee-for-service” provider.
- A fee-for-service provider is one that takes Medi-Cal but is not assigned to a managed care plan. For a list of fee-for-service providers go here.
Continuity of care considerations
- Medi-Cal beneficiaries are allowed to continue seeing providers they had before Medi-Cal in most cases. They are also allowed to continue with medications without a new prescription.
- Additionally, some of these protections are specific to Medi-Cal while others are more broadly applicable to consumers in certain types of managed care plans in California.
ADDITIONAL RESOURCES
- To learn more, see the DHCS page on continuity of care.
- This fact sheet from NHeLP provides an overview of the laws and regulations that require continuity of care for Medi-Cal beneficiaries.