Medicaid Costs and Coverage in California

How much is Medicaid in California? Medicaid cost estimates vary by applicants and their unique situations. In addition to the potential monthly premiums for Medicaid coverage, beneficiaries may be subject to out-of-pocket cost like deductibles and co-insurance depending on their household income, the policy type and which medical services they obtain. Find out how much does Medicaid cost California residents and details about medical services covered by the government program in the below sections.

How much does Medicaid cost in California?

The cost of Medicaid coverage in California is dependent on multiple factors, including copayments, co-insurances and deductibles. The first factor of your Medicaid cost estimates is your copayment, which is a set amount of money you have to pay each time you visit your doctor. This amount is determined by the insurance company that provides your Medicaid coverage. Your copayment is also based off of your allowable cost, which is the maximum amount your insurance plan will pay for certain medical services. A payment type similar to a copayment is a co-insurance payment. The co-insurance payment is a percentage of your allowable cost. The amount of your copayment or co-insurance payment is determined by the services you need and whom you receive them from. For example, the copayment and co-insurance amounts for your doctor’s visits may differ than those you pay for a visit to your dentist. You may have to pay either a copayment or a co-insurance payment, depending on the services you require at the time of your visit.

The second factor used to determine your Medicaid coverage costs is your deductible, which is a fixed amount that you have to pay for your health care before your Medicaid coverage insurance plan takes over the costs of your medical care. Once you have paid the full amount of your deductible, you will only have to pay either your copayment or your co-insurance amount. Learn more about Medicaid costs for beneficiaries by downloading our comprehensive guide.

What services are covered by Medicaid in California?

In California, there are two types of Medicaid coverage benefits that the program covers: mandatory and optional. No matter the types of Medicaid insurance beneficiaries select, federal law requires states to provide certain benefits to anyone enrolled in Medicaid. In addition to those covered health care services, each state is free to decide what other Medicaid coverage it would like to provide its residents with.

Mandatory Medicaid coverage includes certain medical services that every state must offer its residents. In California, the mandatory services that the Medicaid program offers include the following:

  • Professional-certified midwife services

  • Child health services

  • Family planning services

  • Home health services

  • Dentistry services, including medical and surgical

For the most part, mandatory Medicaid coverage services are provided to beneficiaries who from all age groups meet the Medicaid eligibility requirements. However, some Medicaid coverage for health care services may have age limits applied to them. For example, Child Health Services are only for individuals who are younger than 21 years of age. Some services covered by Medicaid may have special conditions. For instance, transportation service is for all ages but only to and from medical providers, as long as the service is medically necessary.

Optional Medicaid coverage are the services that California does not have to cover, but chooses to anyway. Most of the optional services do not have an age limit but some do. As with mandatory Medicaid coverage, there are more optional services available to minors than adults. Different types of hearing aid services and various therapy services, such as occupational, physical and speech require the patient to be younger than 21 years of age. Meanwhile, medical supplies and prescription drugs are available to Medicaid beneficiaries of all ages. Some of the optional Medicaid coverage benefits include the following chiropractic services, dental services, hospice services, prescription drugs and Medicare crossovers. Information about Medicaid covered services is typically issued to beneficiaries after application approval.

What does Medicaid not cover in California?

While Medi-Cal coverage includes many services and programs, it does not cover everything. Medicaid does not cover treatments that are untested or that are still in the testing phase, anything that your Medicare coverage plan does not consider medically effective, a treatment that is not considered normal for your illness or injury and any services that do not have guidelines to regulate them. Your Medicaid coverage also does not cover private nursing services, massage therapy, chiropractic care or medical services given by a family or friend or any kind of cosmetic surgeries that you would use to improve your appearance. While Medicaid coverage includes prescription drugs, it might not include all of them. For instance, fertility drugs, cosmetic drugs and weight-loss drugs are not covered under your Medi-Cal plan for any reason. Download our comprehensive Medicaid guide to learn more about mandatory covered services.

Types of Medicaid Insurance in California

Medi-Cal coverage offers a wide variety of different services and programs. Some other types of Medicaid insurance are as follows:

  • Adult dental benefits

  • Long-term care

  • Programs for workers with disabilities

  • Mental health and substance disorder services

Dental benefits for adults enrolled in Medi-Cal coverage went into effect on January 8, 2018 and provides comprehensive preventative and restorative dental benefits to both children and adults. Your Medicaid coverage of your dental care includes emergency dental services, services provided by a care facility or the department of developmental services. Long-term care is reserved for individuals with Medicaid coverage who currently live in nursing homes. They may qualify for Medicaid’s long-term care program if they are deemed medically needy and meet the income and resource requirements, among other criteria.

The Medi-Cal Workers with Disabilities program is for individuals who are disabled but are still working, either part time or full time. There is no minimum amount of hours or minimum amount you must be paid in order to qualify for the program. However, you will need to show proof of your employment to qualify for full Medicaid coverage. Your income will determine how much your copayments will be. Individuals with lower incomes will pay the normal Medicaid coverage copayments while individuals with higher earnings will pay higher copayments.

Medicaid coverage for services pertaining to mental health and substance use disorders is available under Medi-Cal. Your Medicaid coverage will include services such as outpatient services, withdrawal management, recovery management and physician consultations. Download our detailed Medicaid guide for more information on services covered by the program.