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Friday, December 1, 2023

California Medicaid Frequently Asked Questions Answered

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If you’re wondering how California Medicaid works, there are several resources for you. You’ll find information on Medi-Cal, CalOptima, Share-of-Cost, Prior Approval, and more. We also answer your most frequently asked questions. You’ll be able to decide if this type of health insurance is right for you and your coverage options.


In California, there are a variety of programs to cover the costs of health care. Medi-Cal is one of those programs. Those without health insurance can apply for Medi-Cal to get health coverage. Many counties offer Medi-Cal, and you can contact your local county office for more information and to use.


If you are a California resident considering applying for Medi-Cal health insurance, you may have some questions. Medi-Cal is a state-funded program that provides eligible people with low-cost or free health insurance. You can get an application or make an appointment at a Medi-Cal county office if you wish to use it. The Department of Health Care Services maintains information about Medi-Cal programs, including how to apply.

California Medicaid has many benefits for its beneficiaries. Direct members can see any Medi-Cal provider and have no out-of-pocket expenses, but they need to obtain Prior Approval for certain services. A PHC has a member services department to assist Direct Members. Direct members may also pay a set amount to their providers each month, known as SOC, but the Medi-Cal office determines this amount.


If you’re a member of California Medicaid, you may have Share-of-Cost questions. These monthly payments are set by Medi-Cal and are required if you want to see certain providers. Your Medi-Cal office will provide the necessary information to understand SOC and how much you have to pay.

Share-of-Cost beneficiaries account for a disproportionate share of the program’s expenditures. In October 2007, they accounted for less than 1% of all Medi-Cal beneficiaries but consumed nearly 15% of the program’s fee-for-service expenses. In the fiscal year 2006-07, those costs totaled $2.2 billion. The State of California is now considering budget actions that may impact Medi-Cal’s share-of-cost component. This issue brief provides an overview of share-of-cost Medi-Cal and describes the current policy issues that may affect it.

Prior Approval

Before a prescription can be filled out, a California Medicaid prior authorization form must be filled out. This form must be filled out by the physician prescribing the medication. Even though Medi-Cal pharmacy benefits cover most prescription medications, a physician who prescribes a drug not on the PDL, must justify the diagnosis in the prior authorization form. The process can take several days, and approval is not guaranteed. The patient will be given alternative treatment options if prior authorization is denied.

Although prior authorization is required for many procedures, the process differs from one payer to the next. Typically, the payer requests administrative and clinical information from the patient and treating physician. According to the American Medical Association, 90% of physicians report that prior authorizations constitute a significant problem and negatively impact clinical outcomes.

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