How much does my Medi-Cal plan cost?

Medi-Cal monthly capitation rates can range from $415 to $575 for individuals under the expanded MAGI Medi-Cal in California.

With the expansion of Medicaid in California a large number individuals and families are now enrolled in a Medi-Cal health plan. The expanded Medi-Cal managed health care plans must cover all the same benefits as private health insurance purchased through Covered California. There is no cost to the consumer in terms of monthly premium, deductible, coinsurance or copayments. However, enrollment in these plans does cost something and I’m often asked how much these plans cost the tax payer.

Expanded Medi-Cal increased enrollment by 69%

In December 2013, the month before expanded Medi-Cal opened to all Californian’s based solely on their income, there were 6,026,905 individuals in Medi-Cal managed care plans. This number included a variety of people who were eligible Medi-Cal for a various reason including children, adults, disabled, Medicare low income, breast and cervical cancer patients, and individuals in long term care facilities.

Covered California is much smaller than Medi-Cal

In January 2016 the number of people enrolled in Medi-Cal health plans had swelled to 10,206,349, an increase of 69%. The bulk of the new Medi-Cal enrollments were from individuals and families who Covered California determined were eligible for Medi-Cal because their incomes were below 138% of the federal poverty line. The new MAGI (Modified Adjusted Gross Income) Medi-Cal only considers a household’s income and not their assets such as bank accounts, cars, or homes. (By way of contrast, Covered California has approximately 1.5 million individuals enrolled in health plans as of January 2016.)

Medi-Cal capitation rates can be over $500 per month

The average monthly cost for these MAGI Medi-Cal health plans can range from $415 to $575. Monthly premiums to the Medi-Cal HMO plans vary based on the plan sponsor and county the plan is offered in. The Department of Health Care Services generates enrollment and capitation rate summary reports for Medi-Cal. The capitation rate is monthly premium amount paid to a health plan for specific groups of enrollees. Capitation rates can be higher based on certain conditions such as if the person is disabled, has breast or cervical cancer, or is pregnant.

Billions of dollars paid to private for profit Medi-Cal health plans

If the additional 4,179,444 Medi-Cal enrollment increase is from the expanded MAGI Medi-Cal program, then a conservative estimate of the monthly premium amount based on the lowest capitation amount of $415 equates to $1,734,469,260 being expended on their behalf every month. In Los Angeles County, for January 2016, the Health Net Medi-Cal plan had an enrollment of 1,011,964. The Lower Bound capitation rate for the Health Net of California Los Angeles plan was $446.12 per month. That translates into $451,457,379 per month that Health Net is receiving for their Medi-Cal enrollments in Los Angeles alone.

Medi-Cal is a critical safety net

The claims expense for Medi-Cal health plans can be very high since they are covering some of the most vulnerable of our population with significant health challenges. On the other hand, under the expanded Medi-Cal, there are lots of young and healthy individuals who never go to a doctor. Many of these newly enrolled young people are college students who utilize their campus health centers and never visit a physician, clinic, or hospital off-campus. The net result is the claims expense for these young people is very low.

Medi-Cal enrollment by County and Health Plan

The actual Medi-Cal health plan enrollment is handled by each county with in the state. Some of the counties may offer their own local county Medi-Cal plan or offer two or more HMO plans to county residents. Medi-Cal Plans by County. While the latest posted reports are from June 2015, it will give you an idea of the cost per person by county and health plan.

Medi-Cal capitation rates by county and plan

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Medi-Cal report data available at the links below

Medi-Cal Enrollment Reports

• http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDMonthlyEnrollment.aspx

Medi-Cal Manage Care Financial Reports

• http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDFinancialReports.aspx

Most people feel very fortunate to have Medi-Cal. Many folks have expressed to me that even though they can’t necessarily afford the health insurance premiums for private health insurance, they would be willing to accept some copayments for health care services under the Medi-Cal health plans. If some sort of cost sharing was built into the expanded MAGI Medi-Cal plans, that would help reduce the overall monthly cost to government.