Roughly half the people who have Medi-Cal coverage are enrolled in a Medi-Cal Managed Care plan, but they account for less than 20% of the total service spending. These health plans have networks of providers, including doctors, pharmacies, clinics, labs, and hospitals. Subscribers must use the providers in their network when accessing health care services. 
The following link will take you to a site that contains a list of all health plans doing business in California that are regulated by the Department of Managed Health Care.

 

http://wpso.dmhc.ca.gov/hpsearch/viewall.aspx

 


Evolution of Medi-Cal Managed Care

California started shifting a signifcant portion of the Medi-Cal population into managed care in the early 1990s, as did many commercial health care carriers. The primary cause of this shift was out of concern about the rapid increase in health care costs and the lack of access to primary health care services. As a result, this huge shift brought about dramatic changes in how health care services are both financed and administered. Compared to other state Medicaid programs, California has a larger share of its beneficiaries in fully capitated managed care, but a smaller share in managed care overall.
 
There are approximately 3.8 million Medi-Cal beneficiaries in 25 counties who receive their health care through three main models of managed care:
 
  •  Two-Plan Model
  • County Organized Health Systems (COHS)
  • Geographic Managed Care (GMC)
 

 

Providers & Beneficiaries

  •  Medi-Cal providers who wish to provide services to managed care enrollees must participate in the managed care plan’s provider network. 
  • Medi-Cal beneficiaries are enrolled in managed care according to the model that applies to their given county. With the exception of those living in areas with a County Organized Health System, enrollment in managed care is independent from the general enrollment into the Medi-Cal Program.

 


Related Laws

 
Knox-Keene Act
 
The Knox-Keene Health Care Service Plan Act of 1975 is the set of laws that regulate managed care in the State of California. The Department of Managed Health Care (DMHC) is the agency responsible for enforcing these and other related laws & regulations. For provider assistance, their contact telephone number is 877-525-1295.
 
 
 
  Rogers Amendment
 
Payment to non-contracting Medi-Cal managed care plans for emergency services
 
Section 6085 of Congress’ Deficit Reduction Act (DRA) of 2005, also known as the “Rogers Amendment,” set payment for emergency services provided by Medicaid health plan out-of-network providers at the Medicaid fee-for-service rates in each state. One of the main reasons for this legislation is, in the absence of a contract or state regulatory guidelines, charges to the health plan (and ultimately the state’s Medicaid program) for these out-of-network services are often significantly higher than the fee-for-service rate schedule in that state. Out-of-network payment disputes lead to an adversarial and costly negotiation process that often leads to litigation, driving up costs in Medicaid. California went on to enact Welfare and Institutions (W&I) Code Section 14091.3 in order to comply with this section of the DRA, limiting the amount Medi-Cal managed care plans shall pay non-contracted hospitals for emergency services.*
 
According to DHCS, “Rogers Amendment” requires that non-contracted hospitals shall accept as payment in full the amounts that the provider could collect if the beneficiary received medical assistance through the Medicaid fee-for-service program. Section 6085 further states that in a state where rates paid to hospitals are negotiated by contract and not publicly released, the payment amount for emergency services would be the “average contract rate that would apply” for general acute care or tertiary hospitals.* Essentially, it mandates that final reimbursement rates become effective once published by DHCS and shall apply to all emergency inpatient services provided by non-contracted hospitals since January 1, 2007 (the effective date of DRA Section 6085). 
 
Since implementation, “Rogers Amendment” has has generally been effective in establishing reasonable payments for out-of-network emergency services and in preventing disputes over payments.
 
 
 
 
Footnotes:
 
* Non-contracted hospital: is a general acute care hospital, including hospitals that contract with the Department of Health Care Services (DHCS) under the Medi-Cal Selective Provider Contracting Program (SPCP), that does not have in effect a contract for general acute care inpatient services with a Medi-Cal managed care health plan.
 

Tertiary hospital: is a Children’s Hospital, as specified in W&I Code section 10727, or a hospital that has been designated as a Level I or Level II trauma center by the Emergency Medical Services Authority established pursuant to Health and Safety Code section 1797.1.

Rogers Amendment Average Rates Graph

 

CMAC Regional Average Rates for Non-Contracted Hospital Emergency Inpatient Services
 
 
 
 
 
 
 
 
Regions

 

Rate Periods
San Francisco / Bay Area
Southern California
Other
Average
Average
Average
Non Tertiary
Tertiary
Non Tertiary
Tertiary
Non Tertiary
Tertiary
01/01/07 – 06/30/08
$1,594
$2,468
$1,771
$2,742
$1,797
$2,893
07/01/08 – 06/30/09
$1,771
$2,742
$1,283
$1,998
$1,340
$2,086
07/01/09 – 06/30/10
$1,797
$2,893
$1,411
$1,944
$1,508
$1,980
07/01/09 – 06/30/10*
$1,707
$2,749
$1,273
$1,982
$1,432
$1,881
 
 
 
 
 
 
 
* With 5% rate reduction for post-stabilization general acute care inpatient services
 
 
 
 
 
 
 
 
 
 
San Francisco Bay Area:
Counties of Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano and Sonoma
Southern California:
Counties of Los Angeles, Orange, Riverside, San Bernardino and Ventura
Other Areas:
All other counties or Combined Statistical Areas