What is a Managed Care Medi-Cal Plan?

Individuals enrolled in Medi-Cal are frequently placed into health plans that manage their care.
These health plans are required to issue the same services as "Straight" Medi-Cal (also known as Fee for Service Medi-Cal). The plans are private companies who are issued money from the State of California to care for Medi-Cal patients. These plans have their own networks of providers and restrict the care a patient can get to those networks. 

How do I change my Managed Care Medi-Cal Plan?

If you are not happy with your medical plan, you can choose another medical plan, if available.
To change your medical plan, call Health Care Options at 1-800-430-4263 (TTY 1-800-430-7077). 
Or you can complete and mail a Medi-Cal Choice Form.
Health Care Options will send you a letter confirming that your plan has changed, however the fastest way to confirm this is to ask Health Care Options when you call when the new plan will be effective.

Do I have the option to not participate in a Managed Care Medi-Cal Plan?

Sometimes. If the provider you are wanting to see is not In-Network with a plan in your county, and you have not been enrolled in a plan yet, you may be able to request that the provider file a Medical Exemption Request (also known as an MER) to keep you from being enrolled in a plan (and on "Straight" Medi-Cal). 

What is an IPA/Independent Physician Association/Medical Group?

The plans sometimes further delegate their patients to more specific groups of physicians that can be known as IPAs (Independent Physician Associations) or Medical Groups. So while you may be a member of a plan, you may only be able to see a provider who is associated with a specific smaller group within that plan. The group tends to also manage the billing component of your care. 

How do I change my IPA/Medical Group?

Call the plan directly (the Member Services number should be on the back of your card) and tell them you need to change your group. Health Care Options does not handle group changes, only plan changes.

What are my rights regarding birth with a Licensed Midwife?

Medi-Cal beneficiaries (including those enrolled in a Managed Care Medi-Cal plan) have a right to receive the full scope of LM practice, without preauthorization or physician referral, per CA SPA 15-018.
​This should be fully covered with no share of cost under full-scope Medi-Cal.

Additionally, Medi-Cal Managed Care plans are responsible for having one (1) Licensed Midwife in-network and providing timely access to these covered services, per APL 18-022.

What can I do if these rights are being violated?

If you are enrolled in a Medi-Cal Managed Care plan, we suggest the following steps:
1. File a grievance with your Managed Care Health Plan.
Information about timelines and requirements for grievances can be found here.
Cite CA SPA 15-018 and APL 18-022 (links below).
2. File an appeal with your individual Managed Care Health Plan. Cite CA SPA 15-018.
3. File a complaint with the Department of Managed Health Care.
4. Request a Fair Hearing through Medi-Cal/DHCS.

If you are enrolled in Fee-For-Service ("Straight") Medi-Cal, we suggest you directly request a Fair Hearing through Medi-Cal/DHCS.

What resources can I provide to my Managed Care Medi-Cal plan regarding their need to cover Licensed Midwife care?

State Plan Amendment 15-018, which adds Licensed Midwives to the State Plan.
All Plan Letter 18-022, which outlines requirements for Licensed Midwife coverage.

What can I do if I believe I'm being denied Licensed Midwife coverage by Medi-Cal based on discrimination?

If you think discrimination has affected your benefits or services, you may file a discrimination complaint with the DHCS Office of Civil Rights below:

Office of Civil Rights
Department of Health Care Services
P. O. Box 997413, MS 0009
Sacramento, CA 95899-7413
Phone: (​916) 440-7370
Email: [email protected].