For all Medi-Cal applicants, there are new, simplified procedures for Medi-Cal eligibility that will begin January 1, 2014. Eligibility is based upon income, as required by the ACA. To verify income and other eligibility data, we will rely on faster, more convenient electronic methods whenever possible. Medi-Cal will still accept applications and enroll individuals who qualify using today’s eligibility procedures. Periodic redetermination of eligibility for those who are enrolled will also be much simpler and will be done electronically whenever possible.
Medi-Cal currently provides a core set of health benefits, including doctor visits, hospital care, immunization, pregnancy-related services and nursing home care. The Affordable Care Act ensures all Medi-Cal health plans offer what is known as Essential Health Benefits (EHB). These ten comprehensive services include the following categories:
- Outpatient (Ambulatory) services
- Emergency services
- Maternity and Newborn care
- Mental Health and Substance Use Disorder Services, including Behavioral Health Treatment
- Prescription Drugs
- Programs such as physical and occupational therapy (known as Rehabilitative & Habilitative Services) and devices
- Laboratory services
- Preventive and wellness services & chronic disease management
- Children’s (Pediatric) services, including oral and vision care.
Starting in 2014, the array of mental health and substance use disorder services will expand to better meet the needs of individuals eligible for Medi-Cal. The following mental health benefits will be available through Medi-Cal managed care plans or the fee-for-service delivery system:
- Individual and group mental health evaluation and treatment (psychotherapy)
- Psychological testing when clinically indicated to evaluate a mental health condition
- Outpatient services for the purposes of monitoring drug therapy
- Outpatient laboratory, drugs, supplies and supplements
- Psychiatric consultation
Specialty mental health services currently provided by County Mental Health Plans will continue to be available.
The following substance use disorder services benefits will also be made available to eligible Medi-Cal beneficiaries:
- Voluntary Inpatient Detoxification
- Intensive Outpatient Treatment Services
- Residential Treatment Services
- Outpatient Drug Free Services
- Narcotic Treatment Services
Dental care, vision services and speech therapy are generally available only to children and youths under age 21, but certain adults and pregnant women are also eligible for these services. Dental services will be available to all adults starting May, 2014.
Dental benefits for adults 21 and older have been restored by the Center for Medicare and Medicaid Services**. You can find a Medi-Cal dentist on the Denti-Cal Search Engine. For information on children's dental service, visit the Denti-Cal website.
The following benefits have now been restored:
- Exams and x-rays
- Fluoride treatments
- Anterior root canals (front teeth)
- Prefabricated crowns
- Full dentures
- Other medically necessary dental services
Denti-Cal adult benefits that will remain in place and do not change as a result of the restoration:
- Pregnancy-related services
- Emergency services
- Services provided to residents of an Intermediate Care Facility/Skilled Nursing Facility
- Services provided to consumers of the Department of Developmental Services
**Dental and vision services are available with some limitation. Learn more about dental benefits and further clarification by calling 1-800-322-6384 or visit Denti-Cal .
The Medi-Cal program pays for medical premiums and services. Federal and state law may require these costs to be repaid when the Medi-Cal recipient dies. Click here for information about the Estate Recovery (ER) Program.