Medicaid is better known as Medi-Cal in the State of California and there are approximately six million people enrolled in various managed care plans, including but not limited to Anthem Blue Cross, Health Net, and LA Care (California Department of Health Care Services, 2013). As of 2011, the national enrollment statistics for Medicaid and managed care include approximately 23.1 million Americans, with a total Medicaid enrollment of 40.1 million people (Medicaid.gov, 2012). Therefore, almost 58 percent of all Medicaid users are enrolled through managed care plans (Medicaid.gov, 2012).
There are a number of different types of Medi-Cal managed care plans in the state, including the County Organized Health System, the Two-Plan Model, and the Geographic Managed Care plan (Medi-cal.ca.gov). The County Organized Health System is located in such counties as Monterey, Napa, Santa Barbara, and Ventura; the Two-Plan Model is located in Los Angeles, San Bernardino, Riverside, San Francisco, and other counties; and the Geographic Managed Care Model is located in Sacramento and San Diego (California Department of Health Care Services, 2013). The County Organized Health System is comprised of approximately one million enrollees, the Two-Plan Model has 3.6 million enrollees, and the Geographic Managed Care Plan has 600,000 enrollees (California Department of Health Care Services, 2013).
The manner in which Medi-Cal providers receive payments is important because it supports their revenue streams and continued growth, in spite of an increasingly competitive and regulated industry profile. The managed care organization must pay a capitation payment in order to participate and to accept Medi-Cal patients (Santa Clara County, 2013). In general, “in exchange for a comprehensive array of health care services at a fixed monthly premium, enrollees in managed health care plans typically face the choice of using participating health care professionals and facilities or incurring higher out-of-pocket costs for treatment” (National Council on Disability, 2013). This strategy is important because it demonstrates the need to remain as cost effective as possible when providing care to Medi-Cal patients throughout the State, regardless of the managed plan care plan that is used (National Council on Disability, 2013). In addition, it should be noted that “because Medicaid payment rates are generally lower than commercial rates, provider networks and access to out-of-plan services typically are more tightly controlled under Medicaid managed care plans than they are under employer-sponsored and Medicare Advantage plans” (National Council on Disability, 2013). In this manner, it is likely that there is a continuous push to obtain adequate reimbursements and timely payments for Medi-Cal benefits because they are provided at lower rates than other services (National Council on Disability, 2013).
The Medi-Cal system in the State of California is complex and challenging in many ways and requires expert knowledge and understanding to effectively navigate the system and its mandates. Due to the nature of the Medi-Cal system and its provision of services for lower income individuals and families, it is important to recognize that the necessity of the insured to provide a significant portion of the cost does not generally exist (National Council on Disability, 2013). In this context, it is observed that managed care organizations are required by state and federal laws to require their participants to contribute a very small amount of the costs associated with the provision of care and treatment for specific healthcare services (National Council on Disability, 2013). From this perspective, it is likely that the cost sharing component will remain low and consistent with current figures, there is a greater likelihood that the type of service providers will also be consistent and the willingness to seek out providers that are more expensive will be minimal (National Council on Disability, 2013). These efforts are important because they demonstrate the importance of keeping costs affordable for low income individuals and families who require Medi-Cal to begin with so that they do not face the burden of excessive costs and out-of-pocket spending (National Council on Disability, 2013).
It is believed that the managed care system and its primary subsets under the Medi-Cal system in the State of California are important providers of care and treatment to millions of residents throughout the state. The efforts made with the provision of healthcare access and services for low income individuals and families requires an effective understanding of the elements and opportunities that are available these residents when they require different types of healthcare services to meet their needs. At the same time, the provision of these services varies from one geographic region to the next, with three primary models in place to accommodate California residents who are categorized as low income.
It is expected that the provision of healthcare services will encourage the growth and development of new ideas and strategies to keep costs as low as possible, particularly since the passage of the Affordable Care Act, which places new mandates on insurance providers and managed care organizations of all types to provide affordable options for all individuals and families. These efforts must demonstrate that there are significant factors associated with obtaining adequate and consistent access to healthcare services that will emphasize improved quality of care and treatment for all persons in the State of California. Although Medi-Cal is designed for low income individuals and families, it provides many important benefits that must remain cost effective without compromising the integrity or the quality of care that is provided to patients. In this manner, managed care organizations within the Medi-Cal system must continue to explore their options to remain efficient and cost effective without damaging their reputations and running the risk of providing lower quality care and treatment to patients who require care in different forms.
California Department of Health Care Services (2013). Medi-Cal managed care enrollment
reports. Retrieved from
California Department of Health Care Services (2013). Medi-Cal managed care program fact sheet. Retrieved from http://www.dhcs.ca.gov/provgovpart/Documents/MMCDModelFactSheet.pdf
Medicaid.gov (2012). Medicaid managed care enrollment report. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf
Medi-cal.ca.gov. MCP: An overview of managed care plans. Retrieved from http://www.google.com/url?sa=t&rct=j&q=medi-cal%20types%20of%20managed%20care%20plan&source=web&cd=3&ved=0CD0QFjAC&url=http%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart1%2Fmcpanover_z01.doc&ei=Jui4UcKMMcK6igLa8YBA&usg=AFQjCNEZrUg6lKxM8YqxKfztECMgviHXwA&cad=rja
National Council on Disability (2013). Chapter 1. An overview of Medicaid managed care. Retrieved from http://www.ncd.gov/publications/2013/20130315/20130315_Ch1
Santa Clara County (2013). Health care options/managed care. Retrieved from http://www.sccgov.org/ssa/medical/mcchap15.pdf