Main Content
Member News

Medi-Cal Changes Could Put County Finances and Approximately 650,000 Lives at Risk

September 13, 2021

Healthcare can be complicated. Rules, processes, criteria and requirements have been evolving for decades to ensure quality care is delivered and individuals' lives are improved. This is especially true in Medicaid, which serves the most vulnerable populations across our country. Medicaid programs are different in every state, and in California, where Medicaid is referred to as Medi-Cal, programs can vary by county. There are delegated models, local initiatives, regional plan models, COHS/single plan models and more. Additionally, local officials, who are not necessarily Medi-Cal experts, have the authority to petition for program changes when they believe change is needed. Sometimes this happens without much public awareness because it's not always easy to explain. Also, because Medi-Cal is so complex, officials take the risk of making uninformed decisions that can result in unintended consequences.

5 Things to consider before transitioning to a County Organized Health System (COHS)/Single Plan Model
5 Questions to ask if you are considering a County Organized Health System (COHS)/Single Plan Model

COHS explained

In several California counties, mostly rural north counties, local officials have to make decisions whether to change their Medi-Cal programs from regional plan models to a single plan model or Community Operated Health Plan (COHS). These counties currently employ a model that relies on multiple healthcare organizations to coordinate Medi-Cal benefits for members. Some of these organizations are large, nationally recognized health plans with vast expertise in customizing Medicaid programs. They are backed by Fortune 500 parent companies, funding, resources, infrastructure, manpower and decades of relevant experience. They offer evidence-based best-practices along with a community presence with local staff, offices and supports that have been customized to address the unique needs of members within each community.

COHS, on the other hand, are small, local plans that claim to be better positioned to serve local communities - because they are small and local. They claim to better understand local needs. They are not as resourced as regional plans - financially or administratively. They would be required to build new partnerships, infrastructure and systems to take over Medi-Cal management, and would have to be accredited, agile and financially backed to meet the continually evolving and complex requirements of Medi-Cal - all things that define regional plans' expertise.

Financial implications

Switching to a COHS also has financial implications for a county. In a regional model, health plans take on all financial risks when costs of care rise (as we've seen during the pandemic), and when regulatory changes require funding to build new systems, infrastructure and capabilities. In a COHS, the county shares financial risks and may have to come up with unbudgeted funds to meet requirements.

Care disruptions

Making the switch also means that Medi-Cal members' care would be disrupted. Members would have to move to a new health plan and risk losing advanced services and benefits regional plans have spent years creating. It means members would lose access to innovation that regional plans have implemented to expand healthcare access beyond county borders, such as telehealth, digital solutions and ECHO programs that enable access to the nation's leading specialists. Also, if a COHS plan doesn't meet members' needs, members no longer have the choice to switch to another plan that works better for them.

What to consider

Currently, ten rural north California counties, along with Alameda, Contra Costa, Imperial, Mariposa and San Benito are considering switching to a COHS. Approximately 650,000 Medi-Cal members would be impacted. There isn't much awareness about this potential switch - possibly because it's complicated. It also makes one wonder how informed county decision-makers are about implications of a switch. Maybe it's time to slow down, ask questions and urge county supervisors to learn more before making hasty decisions about complicated changes.