Medicaid Costs and Coverage in California

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Medicaid applicants often ask, “How much is Medicaid in California and what services does the program cover? The cost for CA Medicaid coverage and the services Medicaid provides may vary according to the beneficiary’s status. Understanding the types of Medicaid insurance coverage that are available is the key to understanding the program. Furthermore, it is also critical to answer the question “What does Medicaid not cover?” because the program does not cover every service you may receive. Medicaid beneficiaries may be asked to pay some out-of-pocket costs, like copayments, coinsurance, deductibles and more in order to receive medical care in different situations. This is why understanding Medicaid costs and coverage is critical before you apply for Medicaid enrollment. To get more information on Medicaid cost estimates and Medicaid covered services, review the information provided in the following sections.

What services are covered by Medicaid in California?

The services covered by Medicaid in California include state-mandated benefits and several optional benefits that are covered by the state. There is some flexibility when it is time to determine what Medicaid covers, since the Medicaid program receives its funding from both federal and state governments. Mandatory Medicaid covered benefits are the services that each state is required to include by law. However, optional benefits are up to the discretion of each individual state, and they are decided based on how much funding is available. It is very important to know that mandatory Medicaid coverage may still come with required copays or partial payments. These copays or partial payments will depend on each applicant’s eligibility level. The Affordable Care Act ensures that Medicaid beneficiaries are entitled to what the Affordable Care Act calls “essential health benefits.” These benefits are what the government deems to be essential to living a productive and healthy life. A few of the types of CA Medicaid services covered by mandatory benefits include:

  • Dental and vision services for beneficiaries younger than 21 years of age.
  • Emergency services.
  • Hospital services, inpatient or outpatient.
  • Laboratory services.
  • Maternity and newborn care.
  • Prescription drugs.
  • Preventative care, wellness services and services to manage chronic diseases.
  • X-rays.

To learn about other services covered by Medicaid, you can download our comprehensive Medicaid guide today.

What services does Medicaid not cover in California?

“What does Medicaid not cover in California?” is the second critical question that many Medicaid applicants ask. Knowing what services are not covered by Medicaid are just as important to know as the mandatory benefits. This will prevent Medicaid coverage beneficiaries from expecting to receive services that they are not eligible to receive under the California medical assistance program. Some of the services that are not covered by Medicaid in CA include:

  • Cosmetic surgery or cosmetic procedures that are not medically necessary.
  • Dental and vision services for any Medicaid beneficiaries 21 years of age or older.
  • Erectile dysfunction drugs and therapies.
  • Infertility diagnosis and treatment.
  • Non-medical equipment.

To learn more about services not covered by Medicaid, you can download our complimentary Medicaid guide.

How much does Medicaid cost in California?

The cost of Medicaid in California is the final critical topic for prospective Medicaid applicants. Medicaid cost is an important topic because many Medicaid beneficiaries in California are on low or fixed incomes, and they cannot afford a large hospital bill. CA Medicaid cost estimates tend to be non-existent or minimal, but it is still a good idea to note that there may be costs associated with the Medicaid program before applying for Medicaid.

One of the reasons why California Medicaid cost estimates are extremely minimal or non-existent is because this medical assistance program provides benefits for primarily low-income, elderly, disabled or very ill individuals. Also, if there is a copayment on a service that is covered by Medicaid, the copayment is subject to a maximum price limit. California’s medical assistance program gets this limit by comparing the Medicaid applicant’s household income to the Federal Poverty Level chart. Once the state has assessed the household’s income and other Medicaid eligibility requirements, the applicant will receive a letter from the Medicaid office. This letter will inform the Medicaid applicant of the maximum copayment he or she will have for any services. However, it is up to the primary care provider or medical facility to decide whether or not to charge the full co-payment amount, and the provider cannot charge a higher fee for services than the maximum copayment limit. The costs of CA Medicaid copayments may fluctuate based on how much funding is available.

Also, some California Medicaid coverage beneficiaries, including minors and Native Americans, may be completely exempt from copayments or out-of-pocket costs. There are also some CA Medicaid covered services that do not require the Medicaid beneficiary to pay a copayment at all. These include emergency medical care, the Care and Treatment program, Low Income Health Population services, various disabled and senior care programs and AIDS Healthcare Foundation services.