This dataset contains the total number of Medi-Cal Managed Care enrollees based on the reported month, plan type, county, and health plan.

This dataset includes the total number of individuals enrolled in Medi-Cal by eligibility group: Modified Adjusted Gross Income (MAGI), non-MAGI, and Children’s Health Insurance Program (CHIP). The groups are defined by the Centers for Medicare and Medicaid Services (CMS) Performance Indicators (CMSPI) reporting requirements. The Department of Health Care Services (DHCS) submits eligibility and enrollment data regarding Medicaid and CHIP monthly to CMS. The enrollment data represents enrollment totals as of 60 days after the eligibility month (indicated as “Reporting Period” in the dataset). CMS publishes the state total enrollments on the CMSPI website. The total enrollment comprises of individuals who are eligible for full scope Medi-Cal by MAGI – Child, MAGI – Adult, Non-MAGI Child, Non-MAGI Adult, and CHIP eligibility groups. DHCS does not report to CMS the total enrollment in limited scope Medi-Cal or state-only funded programs (indicated as the “Non-CMSPI” in the dataset).

This dataset contains data pertaining to the full scope expansion of the Adult Medi-Cal population, regardless of immigration status, within three (3) different age groups, each of the age groups is a result of different California legislation. The different age groups are identified below as well as the Senate or Assembly Bill citation for each. Note: Counties with zero individuals enrolled during a reporting period are not included in the dataset.

• Age 19-25 Young Adult Expansion Population: The datasets include the monthly count of individuals ages 19 through 25, by county, receiving full scope Medi-Cal benefits. The counts reflect the total number of eligible individuals enrolled during the month. California provides full scope Medi-Cal benefits to young adults ages 19 through 25, regardless of immigration status. Lawfully present individuals ages 21 through 25, who are not in a pregnancy aid code, are included in this count. Individuals in the dataset are eligible for federal financial participation for their emergency and pregnancy-related services. The Young Adult Expansion program was implemented January 1, 2020, pursuant to Senate Bill 104 (Chapter 67, Statutes of 2019), California Welfare and Institutions Code Section 14007.8.

• Age 26-49 Adult Expansion Population: The datasets include the monthly count of individuals 26-49 years of age, by county, receiving full scope Medi-Cal benefits. The counts reflect the total number of eligible individuals enrolled during the month. California provides full scope Medi-Cal benefits to adults 26-49 years of age, regardless of immigration status. Lawfully present individuals 26-49 years of age, who are not in a pregnancy aid code, are included in this count. Individuals in the dataset are eligible for federal financial participation for their emergency and pregnancy-related services. The Age 26-49 Adult Expansion program was implemented January 1, 2024, pursuant to Senate Bill (SB) 184 (Chapter 47, Statutes of 2022), California Welfare and Institutions Code Section 14007.8.

• Age 50 and over Older Adult Expansion Population: The datasets include the monthly count of individuals 50 years of age or older, by county, receiving full scope Medi-Cal benefits. The counts reflect the total number of eligible individuals enrolled during the month. California provides full scope Medi-Cal benefits to adults 50 years of age or older, regardless of immigration status. Lawfully present individuals 50 years of age or older, who are not in a pregnancy aid code, are included in this count. Individuals in the dataset are eligible for federal financial participation for their emergency and pregnancy-related services. The Older Adult Expansion program was implemented May 1, 2022, pursuant to Assembly Bill (AB) 133 (Chapter 143, Statutes of 2021), California Welfare and Institutions Code Section 14007.8.

Medi-Cal law, Welfare and Institutions Code (W&I Code), sections 14043.6 and 14123, mandate that the Department of Health Care Services (DHCS) suspend a Medi-Cal provider of health care services (provider) from participation in the Medi-Cal program when the individual or entity has:

• Been convicted of a felony;
• Been convicted of a misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service;
• Been suspended from the federal Medicare or Medicaid programs for any reason;
• Lost or surrendered a license, certificate, or approval to provide health care; or
• Breached a contractual agreement with the Department that explicitly specifies inclusion on this list as a consequence of the breach.

Suspension of Entities Submitting Claims for Suspended Providers

Suspension is automatic when any of the above events occurs, and suspended Medi-Cal providers will not be entitled to a hearing under the California Administrative Procedures Act.

Services rendered, prescribed or ordered by a suspended Medi-Cal provider shall not be covered by the Medi-Cal program while the suspension is in effect. California Code of Regulations, title 22, section 51303, subdivision (k), provides that at least fifteen (15) days written notice be given to all affected providers. This list constitutes such written notice. Although the period of suspension may have expired, reinstatement rights are not automatic. The provider must petition for reinstatement and re-enroll with DHCS before being reimbursed for services rendered. Providers suspended as a result of a Medicare action must appeal through the Medicare office before applying for re-enrollment with Medi-Cal.

In accordance with W&I Code, section 14043.61, subdivision (a), a provider of health care services shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from the Medi-Cal program for the services, goods, supplies or merchandise provided, directly or indirectly to a Medi-Cal beneficiary, by an individual or entity that is suspended, excluded or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi-Cal program and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List (S&I List) published by DHCS to identify suspended and otherwise ineligible providers, or any list published by the federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the federal Medicare and Medicaid programs, to identify suspended, excluded or otherwise ineligible providers.

Examples of providers who need to be aware of the provisions of this law, and could be suspended if violating the law are:

1. Billing services that submit claims for Medi-Cal providers who are suspended;
2. Pharmacies that fill prescriptions and bill for services prescribed by a suspended provider;
3. Providers who bill for services under referral or prescription of a provider who is suspended;
4. Providers who employ and submit claims for the services of an individual who is a suspended provider;
5. Physician groups, clinics and institutions that employ and submit claims for the services of an individual who is a suspended provider;
6. Any individuals or entities that enter into a business arrangement and submit claims for or in conjunction with an individual or entity that is suspended.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities. Cross-referencing both lists is recommended to help identify providers who have already been suspended or sanctioned. The S&I List is not all inclusive. Temporary sanctions against providers are not included on the web sites. Temporary sanctions that may be imposed include temporary suspensions, withhold of payments and deactivation.

Dataset contains counts of individuals certified eligible for Medi-Cal, by Month of Eligibility, Zip Code, and Sex, from Calendar Year 2005 to the most recent reportable month. Due to the amount of data presented, below the dataset has been split into three files. All datasets are derived from the most recent reportable months information.