Medicaid Program: How It Improved Care Delivery Through Time

Thousands of residents in Riverside County are now eligible for health insurance under the state’s Medi-Cal program. This coverage is expected to help low-income residents stay healthy and prevent costly medical conditions.

The new coverage is a significant expansion of the state’s Medicaid program and will serve as an essential foundation for improving care delivery. As the program expands and enrollees with complex care needs are enrolled, plans will be challenged to meet the program’s transparency and accountability requirements.

Managed Care Plans

Approximately one-third of California’s 12.5 million Medi-Cal beneficiaries, or 14 million people, receive care through managed care plans. These health maintenance organizations (HMOs) coordinate care through a network of Medicaid doctors, health insurance companies and other partners. These plans offer a range of benefits and services that may include preventive health visits, prescription medications, hospital stays, rehab treatments and more.

In addition to providing primary and specialty medical care, most Medi-Cal plans offer mental health services to their members. A general practitioner or a mental health professional could provide these services.

The Riverside County Medi-Cal services provide health coverage for low-income residents and children. It pays for most of the costs associated with medically necessary services like doctor visits, hospital stays and prescriptions.

According to the Department of Health Care Services, 24 health plans currently contract with DHCS to serve over 70% of all Medi-Cal members in four models: County Organized Health Systems (COHS), Geographic Managed Care (GMC), Two-Plan Model and Regional Model.

These plans, including public plans and Kaiser Permanente, will operate under a new, rigorous contract to provide quality, equitable and comprehensive coverage for their members. The agreement requires partnering with local health departments, community-based agencies and other programs to help Medi-Cal managed care members access the full range of local resources and services. It will also require the plans to meet state standards for accountability.


Low-income people and families can receive free or inexpensive healthcare coverage through the Medi-Cal Program, a state-funded health insurance program. Children and parents are the largest enrollees (about half of the overall caseload), followed by seniors, people with disabilities and undocumented adults.

Medi-Cal is an essential component of the Affordable Treatment Act and was created to assist those who don’t have enough money to pay for their medical treatment. The federal poverty level is the baseline for determining whether someone is eligible for Medi-Cal.

Most people’s incomes must fall below 138% of the federal poverty line to qualify for Medi-Cal. If someone’s income is higher than this amount, they may be able to buy private insurance. For those who don’t qualify for Medi-Cal, other programs can provide cash to help with basic expenses. These include SSI and SSP, CalWorks, the Foster Care or Adoption Assistance Program and Refugee Assistance.

You can apply for these benefits online. You’ll need to complete an application and answer a few questions about your financial situation. 

You’ll also need to share your correct mailing address, phone number and email address with the county to ensure you receive any mail or updates about your Medi-Cal coverage. You’ll need to do this at each renewal or redetermination.


The Medi-Cal Program provides low-income individuals and families health care services, including prescription drugs. It also includes coverage for children, pregnant women, and people with disabilities. Your income and resources depend on whether you’re eligible for Medi-Cal or another state program. 

If you currently receive benefits from another government assistance program, you can continue them while applying for Medi-Cal.

Medi-Cal also covers incontinence supplies, medication for children without private medical insurance, and durable medical equipment such as wheelchairs and hospital beds. As with other Medi-Cal services, durable medical equipment should be purchased from a provider who accepts your primary health insurance and the managed care plan, even if the pharmacy is not part of the managed care plan network.

Out-of-Network Providers

Out-of-network providers are not part of the Medi-Cal network. Your piece of the cost of your medical treatment might increase if you choose an out-of-network physician, and only some services could be covered by your insurance plan. There are several ways to find out-of-network providers near you. You can search the county, city or zip code level to get results for specific geographic areas. You can also ask your medical group for recommendations on which local providers offer the best care.

Consult with your primary care physician or PCP as soon as possible. A good PCP will be your trusted partner throughout life’s journey. Your doctor will help you navigate your healthcare needs, coordinate the best possible care, and advise you on which treatments are covered under the ACA.

The most crucial information to remember is that you need to use providers within your plan’s network to get the best medical care. For example, if you receive care from an out-of-network urologist, your out-of-pocket costs will likely be higher than if you received the same care from a doctor in your medical group’s network. Similarly, your insurance might not cover the cost of an out-of-network doctor treating you in a hospital emergency room.

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