Medi-Cal is California’s state Medicaid program, providing comprehensive health coverage to millions of eligible residents. Services are primarily delivered through a network of private health insurance companies known as Medi-Cal Managed Care Plans, which operate under contract with the Department of Health Care Services (DHCS). Since the state contracts with multiple plans in many areas, beneficiaries must choose the plan that best fits their personal healthcare needs.
The Structure of Medi-Cal Managed Care Plans
The specific managed care plan options available depend entirely on the beneficiary’s county of residence, as the state uses several distinct organizational models. The County Organized Health System (COHS) model, for example, assigns all Medi-Cal beneficiaries in that county to a single, county-run health plan, meaning residents have no plan choice.
In contrast, counties operating under the Two-Plan or Geographic Managed Care (GMC) models offer a choice between two or more health plans. The Two-Plan model typically features a Local Initiative and a commercial plan, while GMC counties contract with multiple commercial plans. Regardless of the model, these systems function much like a Health Maintenance Organization (HMO), requiring the beneficiary to select a Primary Care Provider (PCP) who manages their overall care and coordinates referrals to specialists. Nearly 90% of all Medi-Cal beneficiaries receive their healthcare through one of these managed care systems.
Essential Criteria for Selecting the Best Plan
Determining the “best” plan relies on which one best aligns with personal health needs and existing provider relationships. The most critical step is confirming whether current or desired doctors, clinics, and hospitals are part of a plan’s network before enrolling. Beneficiaries should use the DHCS Managed Care Health Plan Directory to find available plans and then check each plan’s specific provider directory.
A key consideration is the policy on Continuity of Care (CoC), which allows a beneficiary to continue seeing a non-participating provider for a period after enrolling in a new plan. If a verifiable pre-existing relationship exists, a member may request up to 12 months of CoC with a non-network provider to complete a course of treatment. This protection is especially valuable for those with chronic conditions or an ongoing relationship with a specialist.
When evaluating a plan, look at quality data published by the state. The Department of Health Care Services contracts with an External Quality Review Organization (EQRO) to evaluate plan performance in areas like access and quality. Plans must report on specific metrics, including the Healthcare Effectiveness Data and Information Set (HEDIS), which are compiled into the External Accountability Set (EAS).
Patient satisfaction is measured through the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, which gauge member experiences with their plan and providers. Plans that score well on preventive care measures, such as childhood immunizations or diabetes management, indicate a strong commitment to member health.
For prescription medications, all Medi-Cal managed care plans now use a standardized, statewide formulary administered through Medi-Cal Rx. The covered drug list, called the Contract Drugs List (CDL), is the same regardless of which managed care plan a beneficiary chooses. Questions about drug coverage, including prior authorization requirements, should be directed to Medi-Cal Rx, not the health plan itself.
Supplemental benefits related to the state’s CalAIM initiative can be important. These benefits include Enhanced Care Management (ECM) and Community Supports. ECM provides care management for those with complex needs, while Community Supports address health-related social needs like housing transition assistance or medically tailored meals. The availability and quality of these programs differ between plans and offer significant value for beneficiaries needing more than standard medical services.
Navigating Enrollment, Switching, and Appeals
The administrative process for managing a Medi-Cal Managed Care Plan is handled by Health Care Options (HCO), the state’s enrollment broker. When initially qualified, beneficiaries receive a choice packet and must select a plan within a set timeframe, or one will be auto-assigned. The initial selection, or any subsequent change, can be made by contacting HCO by phone or through their website.
Beneficiaries in “choice” counties generally have the right to change their managed care plan, though DHCS has an annual choice period. To switch plans, a beneficiary must contact HCO, and the new enrollment typically becomes effective on the first day of the following month after the request is submitted. For those moving to a new county, the inter-county transfer process requires re-enrolling in a plan available in the new service area.
If a beneficiary has a complaint, they can file a Grievance with their health plan, which must generally be resolved within 30 calendar days. If a plan denies a request for a covered service, medication, or treatment, the beneficiary receives a Notice of Action (NOA), which triggers the Appeal process. The first step is to file an appeal with the managed care plan itself.
If the plan denies the internal appeal, the beneficiary has the right to request a State Fair Hearing with the California Department of Social Services (CDSS) to review the decision. This request must be filed within 90 days of receiving the Notice of Action. For external assistance with conflicts, beneficiaries can contact the Medi-Cal Managed Care Ombudsman Office, which helps resolve issues between members and their health plans.