California
In California:
- As of July 1, 2011, there were 7,580,978 beneficiaries enrolled in the state’s Medicaid program, 4,553,090 of whom were enrolled in some form of managed care.
- Physical and outpatient mental health services are provided through a variety of regional managed care organizations (MCOs)–5 Health Insurance Organizations, 21 commercial MCOs, and 3 Medicaid-only MCOs. These fall under one of five managed care models with varying degrees of county-based public MCO and commercial MCO participation. The state also had 9 physical health Prepaid Inpatient Health Plans as of 2011.
- Inpatient behavioral health services are provided on a fee-for-service basis or as part of county-based community mental health services. The state also had a single mental health PIHP with only 131 enrollees as of 2011.
- Dental services are provided through 13 Prepaid Ambulatory Health Plans that serve 515,046 beneficiaries.
As of 2013, 5,539,321 individuals were eligible for California’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 100% and a participant ratio of 100%. 2,209,031 children received dental services of any kind, with 1,790,996 receiving preventive dental services.
Last updated September 2014.
| Medical Necessity |
The California Welfare and Institutions Code (Section 14059.5) states that:
“A service is ‘medically necessary’ or a ‘medical necessity’ when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”
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| Initiatives to Improve Access |
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| Reporting & Data Collection | The Medicaid program offers Managed Care Performance Dashboards that offer quarterly insights on plan performance, including on consumer satisfaction for children’s families. Performance measure reports on HEDIS scores include data for:
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| Behavioral Health |
Medicaid-enrolled children and adolescents in California receive behavioral health services through county mental health departments. A brochure from the state notifies children and families of behavioral health services available as part of the EPSDT benefit, including:
California’s Medicaid program reimburses for developmental screenings performed with a standardized tool (using the 96110 CPT code). Tools recommended by the state include the Ages and Stages Questionnaires and the Parents’ Evaluation of Developmental Status instruments.
California’s Medicaid program also offers Therapeutic Behavioral Services to Medicaid-enrolled children with mental health needs who are as risk of admission to a hospital or psychiatric health facility. The California Department of Health Care Services provides a statewide list of providers offering these services.
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| Support to Providers and Families |
Support to Families
The California Department of Health Care Services offers a managed care health plan directory to help enrollees choose a plan. Consumer guides offer families comparative information on available health plans, including ratings of:
A “Provider Information Network” tool helps families find Medicaid-participating doctors, dentists, hospitals, and clinics in particular geographic areas.
Support to Providers
The California Department of Health Care Services also offers a “Providers & Partners” website that collects information on a variety of programs, provides forms for providers, and offers resources on policies, procedures, and grant opportunities. Provider manuals on a number of topics are also available on the site.
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| Care Coordination |
California received approval for a Bridge to Reform Section 1115 Demonstration Waiver in 2010. In 2011, under authority provided in the Bridge to Reform waiver, the state launched five pilot projects intended to better coordinate care for children with special health care needs. The projects were designed to support development of medical homes and accountable care organizations that could provide children with whole person care and reduce fragmentation of service delivery.
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| Oral Health |
California has a “Denti-Cal” website dedicated to the Medicaid oral health benefit. The site contains a section on the EPSDT benefit as it pertains to oral health services for children; this section offers examples of supplemental oral health services not covered under the Medicaid state plan but required to be made available for children. Dental provider bulletins offer updates on Medicaid policy for oral health and a dental Medicaid provider manual details available services.
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For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
