Under fee-for-service Medi-Cal, beneficiaries are responsible for
finding primary care providers and specialists who are willing to
accept Medi-Cal; beneficiaries are not matched with a primary
care provider who coordinates their care. The California
Department of Health Care Services (DHCS) establishes fee
schedules, negotiates rates with hospitals, determines medical
necessity criteria and pays provider claims for services
provided.
Medi-Cal Managed Care
In response to rising fee-for-service costs and concerns about
access to care, California began to enroll a significant portion
of the Medi-Cal population into managed care in the 1990s,
although CenCal Health (formerly known as the Santa Barbara
Regional Health Authority) pioneered the shift to managed care
when it opened its doors in 1983, and Contra Costa Health Plan
participated in the earliest version of Medi-Cal managed care
dating back to the 1970s. While the managed care models differ by
county, each of the participating health plans contract with DHCS
and assume full financial risk for all covered services.
Two-Plan Model
Launched in the mid-1990s, the Two-Plan model operates in 14 of
the state’s larger, more urban counties. Under this model,
Medi-Cal beneficiaries have a choice between a local health plan
(known as the Local Initiative) and a Commercial Plan (e.g.,
Anthem Blue Cross, Health Net, Molina Healthcare) competitively
selected by DHCS. Each Local Initiative has been created by
its respective county board of supervisors and is overseen by a
local commission (the one exception is Tulare County in which two
Commercial Plans offer coverage). Both the Local
Initiatives and Commercial Plans contract with DHCS.
LHPC represents all nine of the public Local Initiatives offering
coverage in 13 counties: Alameda Alliance for Health, CalViva
Health, Contra Costa Health Plan, Health Plan of San Joaquin,
Inland Empire Health Plan, Kern Health Systems, L.A. Care Health
Plan, San Francisco Health Plan, and Santa Clara Family Health
Plan.
COHS Model
The six COHS plans operate in 22 counties. The COHS counties
represent a mix of large, urban counties (e.g., Orange County)
and smaller, more rural counties (e.g., San Luis Obispo County).
This model has the distinction of being defined in both state
statute and federal statute (as a Health Insuring Organization,
or HIO). COHS are public entities created by county boards of
supervisors and governed by independent commissions. Under this
model, the state contracts the COHS, and the vast majority of the
Medi-Cal beneficiaries in the county are automatically assigned
to the health plan.
LHPC represents all six of the COHS plans: CalOptima, CenCal
Health, Central California Alliance for Health, Gold Coast Health
Plan, Health Plan of San Mateo, and Partnership HealthPlan of
California.
GMC Model
The GMC model operates in two counties: Sacramento and San
Diego. In these counties, Medi-Cal beneficiaries can choose
among multiple health plans. Under this model, the state
contracts with a number of commercial plans and, in San Diego
County, a non-profit, community-based plan.
LHPC represents Community Health Group, which is the
community-based plan in San Diego County.
Regional Model
The Regional model is the newest Medi-Cal managed care model and
is now operational in the last 20 predominantly rural counties in
California. For the most part, Medi-Cal beneficiaries
residing in these counties are required to enroll in a managed
care plan. In most of the Regional model counties, Medi-Cal
beneficiaries have a choice of two commercial plans that contract
with DHCS. The lone exception is San Benito County in which
beneficiaries may choose between enrolling in the commercial
health plan or remaining in fee-for-service Medi-Cal.
