Medi-Cal

About Medi-Cal

More than 15 million Californians rely on Medi-Cal, the state’s health care coverage safety net, for health insurance. Two-thirds of those on Medi-Cal are people of color and often live in communities with a lack of adequate health care providers. Without significant investments to support providers that deliver health care to California’s most vulnerable, millions living in rural and underserved areas are in jeopardy.

New Federal Electronic Prior Authorization Requirements Finalized

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has finalized policies to advance interoperability and streamline prior authorization processes by using application programming interfaces (API) technology.  

What else to know: The final rule also requires payers to provide a specific reason for denied prior authorization decisions and publicly report certain prior authorization metrics.  

Managed Care Plans to Face Sanctions from DHCS for Poor Performance

What’s happening: Medi-Cal managed care plans (MCPs) will face sanctions from the Department of Health Care Services (DHCS) for failing to meet quality performance standards. 

What else to know: DHCS has issued All Plan Letter (APL) 23-012, which updates and clarifies the policy on the imposition of administrative and monetary sanctions to plans that fail to meet minimum performance for required quality performance measures. 

New Managed Care Plan Changes in January Help Advance Health Equity, Access, and Accountability

What’s happening: Effective Jan. 1, 2024, Medi-Cal managed care plans (MCPs) will operate under a new and revamped contract intended to better advance quality, access, accountability, health equity, and transparency.   

What else to know: Also effective Jan. 1, 2024, MCPs available for enrollment in certain counties will change due to county-elected model changes, the awarding of new commercial MCP contracts, and/or the expansion of direct contracts with Kaiser Permanente.   

Full-Scope Medi-Cal Coverage Expanded to Eligible Adults Regardless of Immigration Status

What’s happening: Effective Jan. 1, 2024, California will provide full-scope Medi-Cal benefits to individuals ages 26 to 49, regardless of citizenship or immigration status, who otherwise meet financial eligibility criteria for the program.   

What else to know: The state previously expanded full-scope eligibility for similarly situated people ages 19 to 25 in 2020 and people 50 and older in 2022.   

DHCS Receives Federal Approval of the 2023-24 Hospital Fee Program

What’s happening: On Dec. 15, the Department of Health Care Services (DHCS) received federal approval of the 2023-24 Hospital Fee Program, originally submitted in March 2023.  

What else to know: The program runs from Jan. 1, 2023, to Dec. 31, 2024, and will provide California’s hospitals with an annual net benefit of approximately $5.3 billion per year on an accrual basis over the 24-month period.    

Area Wage Index Litigation

This page contains important, members-only information related to the Centers for Medicare & Medicaid Services’ recently finalized area wage index policy. To continue, please log in to your member account.