Mandatory Co-pays in Medi-Cal: All Medi-Cal beneficiaries will be required to provide co-payments for services and prescriptions. Pregnant women, children, parents, seniors, and persons with disabilities will be expected to provide payments at the point of service of $5 for doctor and clinic visits, $3 for preferred prescription drugs and $5 for non-preferred drugs. In addition to co-pays for basic clinical and preventive care, patients will be charged $50 each time they go to the emergency room, and $100 for one night in the hospital, which would max out at $200 for two or more nights.
There is no out-of-pocket maximum, and providers can turn patients away who are unable to pay at the point of service. Providers may also hold patients liable for the payment, meaning low-income health consumers could go into debt if they are unable to pay for their health care.
Utilization Caps: Adult Medi-Cal beneficiaries would be subject to a cap of seven doctor or clinic visits annually. A patient may receive more than seven visits if the medical provider indicates the service is “medically necessary”. This is construed as preventing emergency room and inpatient admissions, preventing institutionalization, interrupting ongoing medical treatment, if the service is part of a diagnostic workup to deter emergency admissions, or if the service is required to assess a beneficiaries’ admission to the In-Home Supportive Services Program.
Service Eliminations and Caps on Equipment: Adult Medi-Cal beneficiaries will face eliminations of existing benefits. Those who need hearing aids will be limited to an allowance of $1,510 annually to pay for their devices. Adults will no longer be able to use Medi-Cal for their cough and cold medicine. Adults who are not tube-fed will not be able to use their Medi-Cal benefit to obtain enteral nutrition products, which provide vital nutrition to frail and medically vulnerable people who have problems chewing and swallowing their food.
Elimination of Adult Day Health Care: AB 97 eliminates Adult Day Health Care, but appropriates $85 million in General Fund dollars to develop a new program with the intention of keeping beneficiaries out of institutions.
Healthy Families Premium Increases: For families with incomes between 150-200% of FPL, premiums would rise from $16 to $30 per month per child, maxing out at $90 per month per family. Families between 201-250% FPL would see their premiums rise from $24 to $42 per child per month, maxing out at $126 per month per family.
Healthy Families Co-Pay Increases: Healthy Families beneficiaries will see increased co-pays of $50 for emergency visits and $100-$200 for hospital stays, in accordance with the increased co-pays in Medi-Cal.
Funding Shifts: AB 97 transfers $861 million from the Proposition 63 fund, the Mental Health Services Act, to other existing mental health programs that had been funded through the General Fund. It also transfers from Proposition 10 $950 million from county commissions and $50 million from the state commission on a one-time basis to fund Medi-Cal for children ages zero to five.