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Medi-Cal Integration

Beginning in 2014, the California Exchange will offer Qualified Health Plans (QHPs) to California residents. Many low-income Californians will qualify for either premium subsidies or reduced-cost-sharing or both to help purchase health care coverage in the Exchange. Others will qualify for Medi-Cal,  California’s  Medicaid  program,  or  the Children’s   Health  Insurance  Program  (CHIP) (formerly  Healthy  Families).  Coverage offered through the Exchange must be coordinated with Medi-Cal, and other state health care programs that serve low income Californians. This is a particular concern for individuals who move between the Exchange and other public programs, and families that may have coverage from multiple sources. How programs facilitate a smooth consumer experience, minimize administrative complexity and assure continuity of care are significant issues.

ACA Medi-Cal Expansion

In January 2014, Medi-Cal coverage will expand to include individuals who do not qualify today —primarily childless adults who earn up to 138% FPL and do not have access to affordable employer-sponsored insurance. To begin the transition process, California received approval in November 2010 from CMS to implement  a  Bridge  to  Reform Medicaid  demonstration. Under the waiver, the county expenditures for their medically indigent services could be matched with federal funds to enroll low income uninsured individuals into a transitional health coverage program - the Low Income Health Program (LIHP) - intended to provide interim coverage until the Medi-Cal Coverage Expansion occurs January 1, 2014.

Eligibility Churning

There are a variety of life  experiences that may change an individual’s eligibility, including: changes in family income:, changes in family structure, perhaps due  to  the  birth  of  a  child  or  the  ”aging  out”  of  a  child;  or  re-location for work or to meet family responsibilities. Some may become eligible for Exchange subsidized coverage. Some may get employer sponsored health coverage. Others who lose a job may find themselves without coverage - but eligible for Medi- Cal or Exchange based coverage. This movement between programs is often referred to as “churn”. Although there are many administrative costs and complexities related to churn, the issue of continuity of care may be a greater concern for many beneficiaries and enrollees. To the extent that churn results in individuals changing health plans with different provider networks, there is always the risk of disruption and confusion.

The Exchange must work with both the DHCS and MRMIB to consider the implications of the churn and to identify strategies that will improve the consumer experience, and minimize unnecessary program complexity.

Return to Index of Challenges the Exchange Must Overcome

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