In California, most people, whether in Medi-Cal, Covered California, or other private health coverage, receive their care from health plans. NHeLP works to ensure that these plans provide high quality and accessible care.
Most Californians get their health coverage through a managed care plan. For example, as of July 2023, over 90% of Medi-Cal’s 15 Million enrollees were enrolled in comprehensive managed care health plans statewide. These plans typically receive a fixed per-member, per-month “capitated” fee, regardless of how many services an enrollee may actually need. The managed care plan bears the financial risk if the cost of providing services exceeds the capitated payment. On the other hand, if enrollees use fewer services, the plan keeps the excess payment. Because managed care companies have a financial incentive to limit costs and care, federal and state law and regulations provide an important array of consumer protections for enrollees.
NHeLP works with our partners in California to monitor and enforce the rules that govern managed care plans to ensure that Californians have access to covered services and can execute their legal rights. With our partners, we also work to improve the policies and rules that govern these plans to ensure that California’s protections for managed care enrollees are as robust as possible.
