How Medi-Cal Managed-Care Plans Coordinate Care

Most Medi-Cal beneficiaries receive coverage through managed-care plans that assign each member a primary care provider and coordinate services across specialists, hospitals, and community programs. Understanding how your plan organizes care helps you access the right services at the right time and avoid gaps in treatment.

Medi-Cal serves more than 15 million Californians, and the majority receive their coverage through managed-care plans rather than traditional fee-for-service Medi-Cal. These plans contract with the California Department of Health Care Services to provide comprehensive medical, behavioral, dental, and pharmacy services while organizing care around each member's individual needs. The fundamental goal is to prevent fragmented care—situations where different physicians, specialists, hospitals, and behavioral health providers work in isolation without sharing information or coordinating treatment decisions—and instead create an integrated network that communicates effectively and plans treatment collaboratively.

Managed-care plans operate on a capitated payment model, receiving a set monthly payment per enrolled member from the state. This financing structure incentivizes plans to invest in preventive care, chronic disease management, and early intervention rather than allowing conditions to progress to the point where expensive emergency department visits or inpatient hospitalizations become necessary. Each plan assigns every member a primary care provider (PCP), maintains contracted networks of specialists and hospitals, employs care coordinators who work directly with members who have complex medical or social needs, and increasingly connects medical care with community-based services such as housing assistance, nutrition support, and transportation. Understanding how your specific plan organizes these services, what approval processes apply to different types of care, and how to access care coordination support enables you to use your benefits effectively and obtain needed care without unnecessary delays or administrative obstacles.

This article explains in detail how Medi-Cal managed-care plans coordinate care across multiple providers and settings, what services require advance approval through prior authorization, when and how you can access specialist care, how care coordinators function for members with chronic conditions or complex social needs, what California's CalAIM initiative has changed about care coordination and social service integration, how information flows among different providers involved in your care, and what steps to take when coordination breaks down. The discussion addresses both the structural elements that plans use to organize care and the practical steps you can take to navigate the system successfully.

The Primary Care Provider as Central Coordinator

When you enroll in a Medi-Cal managed-care plan, the plan assigns you a primary care provider—typically a family medicine physician, internal medicine physician, pediatrician (for children), or in some networks a nurse practitioner or physician assistant working under physician supervision—who serves as your main point of contact for routine medical care. Your PCP manages preventive services including age-appropriate screenings (blood pressure, cholesterol, cancer screenings, developmental assessments for children), immunizations, and health maintenance visits. The PCP also diagnoses and treats acute illnesses such as respiratory infections, minor injuries, and common dermatologic conditions, and manages chronic diseases including diabetes, hypertension, asthma, chronic obstructive pulmonary disease, and heart disease. Importantly, your PCP coordinates referrals when you need specialist care, ensuring that the specialist receives relevant medical history, current medication lists, recent laboratory and imaging results, and a clear understanding of what clinical question needs to be answered. This centralized coordination helps ensure that everyone involved in your care understands your complete medical picture, reducing the risk of duplicated testing, conflicting treatment recommendations, or dangerous medication interactions.

Your primary care provider also tracks chronic conditions longitudinally over months and years, adjusting medications as needed, monitoring for complications, and reinforcing lifestyle modifications such as dietary changes, physical activity, smoking cessation, and medication adherence. Because Medi-Cal managed-care plans report performance on quality measures to the California Department of Health Care Services—metrics such as the percentage of members with diabetes who receive annual eye examinations and kidney function tests, the percentage of children who receive recommended immunizations on schedule, and the percentage of eligible adults who complete colorectal cancer screening—your PCP and the plan share aligned incentives to deliver evidence-based preventive care according to established clinical guidelines. Plans often use population health data to identify members who are due for screenings or who have gaps in recommended care, prompting outreach from the PCP's office or the plan's care coordination team.

You can change your primary care provider if you move to a different geographic area, if your current PCP leaves the plan's network, if you experience communication difficulties or a breakdown in the therapeutic relationship, or simply if you prefer a different provider's approach or office location. Contact your plan's member services department to request a PCP change; the plan typically processes the change within a few business days, and the new assignment becomes effective at the start of the following month. When you visit an emergency department, urgent care center, or specialist, those providers generate clinical documentation and often send discharge summaries, consultation notes, or test results to your PCP electronically or by fax. This information loop is essential: without it, your primary care team remains unaware of significant diagnoses, medication changes, or follow-up instructions, creating dangerous gaps where new medications might interact with existing prescriptions, abnormal test results might go unaddressed, or necessary follow-up appointments might be missed entirely.

Specialist Referrals, Network Requirements, and Access Standards

Medi-Cal managed-care plans generally require a referral from your primary care provider before you see a specialist such as a cardiologist, endocrinologist, pulmonologist, rheumatologist, orthopedic surgeon, neurologist, or dermatologist. The referral serves multiple functions: it confirms that your PCP believes specialist consultation is medically appropriate, it communicates the clinical question or problem the specialist should address, it ensures that relevant medical records accompany you to the specialist appointment, and it verifies that the specialist is part of your plan's contracted provider network. Some plans allow self-referral to specific types of specialists—most commonly obstetricians and gynecologists for routine reproductive health care, and sometimes optometrists or ophthalmologists for vision care—without requiring PCP approval, but these direct-access policies vary by plan and by the specific service requested. Always verify your plan's referral requirements before scheduling a specialist appointment to avoid unexpected out-of-pocket costs or appointment cancellations.

When your PCP determines that specialist care is necessary, the office submits a referral request to your plan, typically through an electronic system that routes the request to the plan's utilization management department. The plan reviews the request to confirm that the service is covered under your benefit plan, that it meets medical necessity criteria based on clinical guidelines and evidence-based medicine, and that an appropriate in-network specialist is available within the plan's geographic access standards. California regulations require that managed-care plans provide specialist appointments within specific timeframes: urgent care needs that do not require immediate emergency department treatment must be available within 48 hours, and routine specialist appointments must be available within 15 business days of the request. If your plan cannot provide an appointment with an in-network specialist within these timeframes, the plan must arrange for you to see an out-of-network specialist at no additional cost to you, a process known as a network adequacy exception.

Many specialist consultations, diagnostic procedures, advanced imaging studies (MRI, CT, PET scans), and expensive medications require prior authorization in addition to a referral. Prior authorization is a utilization management process in which the plan reviews detailed clinical information—such as your diagnosis, prior treatments attempted, relevant laboratory or imaging results, and the specific procedure or medication your physician recommends—to determine whether the requested service is medically necessary and covered under Medi-Cal benefits. Your physician's office typically initiates the prior authorization request by submitting clinical notes, recent test results, and a justification statement explaining why the service is appropriate for your condition. California regulations mandate specific response timeframes: standard prior authorization requests must receive a decision within five business days, and expedited requests (used when a delay could seriously jeopardize your health or ability to regain maximum function) must be decided within 72 hours. If the plan denies the authorization, the denial letter must explain the clinical rationale, cite the specific coverage criteria or clinical guideline that was not met, and inform you of your right to appeal the decision.

Emergency medical care never requires prior authorization or a referral, and this protection is absolute. If you experience symptoms suggesting a serious acute condition—chest pain, difficulty breathing, severe abdominal pain, sudden neurological changes such as weakness or speech difficulty, severe trauma, active labor, acute psychiatric crisis with risk of harm to yourself or others, or any other condition where a prudent layperson would reasonably believe that immediate medical attention is necessary to prevent serious harm—go directly to the nearest emergency department or call 911. Your Medi-Cal managed-care plan must cover emergency services regardless of whether the hospital is in your plan's network, and you cannot be balance-billed (charged the difference between the hospital's charges and what your plan pays) beyond any small copayment your plan may require. After emergency treatment stabilizes your condition, the hospital coordinates with your plan for any necessary follow-up care or transfer to an in-network facility if continued inpatient treatment is needed.

Care Coordination for Members with Complex Medical Needs

Members who have multiple chronic conditions, recent hospitalizations, behavioral health diagnoses, or complex social circumstances often qualify for enhanced care coordination services provided directly by the managed-care plan. Care coordinators are typically registered nurses, licensed clinical social workers, community health workers, or trained health educators employed by the plan who work one-on-one with members to organize medical appointments, arrange non-emergency medical transportation, reconcile medication lists after hospital discharge, provide health education tailored to specific diagnoses, and connect members with community resources such as food banks, housing assistance programs, and disease-specific support groups. This personalized support aims to prevent avoidable complications, reduce emergency department visits and hospital readmissions, improve medication adherence, and help members successfully manage conditions at home rather than in institutional settings.

Managed-care plans use clinical data analytics to identify members who would benefit from care coordination, flagging individuals who have had multiple emergency department visits or hospitalizations within a short period, who have diagnoses associated with high complication rates (heart failure, chronic obstructive pulmonary disease, poorly controlled diabetes, serious mental illness, substance use disorders), who have recently transitioned from a hospital or skilled nursing facility back to the community, or who have missed multiple primary care or specialist appointments. Care coordinators may reach out proactively by phone to offer assistance, or you can request care coordination services yourself by calling your plan's member services number and asking to speak with the care coordination or case management department. These services are included in your Medi-Cal coverage at no additional cost to you.

Once assigned, a care coordinator typically schedules an initial comprehensive assessment—either by phone, by video, or in person depending on your needs and preferences—to understand your current medical conditions, medications, recent hospitalizations or emergency visits, barriers you face in accessing care (transportation, language, work schedule, childcare responsibilities), and social needs that affect your health (housing stability, food security, utility assistance, personal safety). Based on this assessment, the coordinator develops an individualized care plan with specific goals and action steps, such as scheduling overdue specialist appointments, arranging transportation to a dialysis center three times weekly, setting up a pill organizer to improve medication adherence, connecting you with a Meals on Wheels program if you have difficulty preparing food, or helping you apply for disability benefits if your medical conditions prevent you from working. The coordinator maintains regular contact—weekly, biweekly, or monthly depending on your needs—to monitor progress, troubleshoot new problems, update the care plan as your situation changes, and serve as a single point of contact who can navigate the often-fragmented healthcare and social service systems on your behalf.

For members who have co-occurring medical and behavioral health conditions—such as depression or anxiety alongside diabetes or heart disease, or serious mental illness alongside chronic pain or infectious disease—some managed-care plans offer integrated care models where a behavioral health care manager works directly with your primary care provider in the same office or through closely coordinated communication. This team-based approach, often called collaborative care or integrated behavioral health, treats mental and physical health together rather than in separate silos. The behavioral health care manager provides brief counseling, monitors psychiatric symptoms and medication side effects, coordinates with psychiatrists for medication management, and works with your PCP to adjust treatment as needed. Research consistently demonstrates that integrated care improves outcomes for conditions such as major depression, generalized anxiety disorder, post-traumatic stress disorder, and substance use disorders, particularly when these conditions complicate the management of chronic medical illness. Ask your primary care provider or your plan's member services department whether integrated behavioral health services are available in your PCP's office or elsewhere in the plan's network.

CalAIM Enhanced Care Management and Community Supports

California's CalAIM (California Advancing and Innovating Medi-Cal) initiative represents a fundamental transformation in how Medi-Cal managed-care plans address the social determinants of health—the economic, environmental, and social conditions that profoundly influence health outcomes but lie outside the traditional boundaries of medical care. Implemented beginning in 2022, CalAIM introduced two major care coordination innovations: Enhanced Care Management (ECM) and Community Supports (formerly called In Lieu of Services). These programs explicitly recognize that for many Medi-Cal members, barriers such as homelessness, food insecurity, unsafe housing conditions, lack of transportation, and involvement with the criminal justice system drive poor health outcomes and high healthcare costs more directly than any purely medical intervention could address.

Enhanced Care Management provides intensive, whole-person care coordination for Medi-Cal members with the most complex needs across medical, behavioral health, developmental, oral health, and social domains. ECM is required for all Medi-Cal managed-care plans and targets seven defined high-risk populations: individuals experiencing homelessness or at risk of becoming homeless; individuals with high emergency department or inpatient hospital utilization; individuals transitioning from incarceration; individuals with serious mental illness or substance use disorders; children and youth in foster care or involved with child welfare; individuals with complex physical, behavioral, or developmental needs requiring care across multiple systems; and adults age 65 and older at risk of nursing facility placement. Members in these populations receive comprehensive assessment, individualized care planning, care coordination across medical and non-medical services, health promotion and comprehensive transitional care, community and social support services referrals, and coordination of and referrals to community and social support services.

ECM teams—composed of nurses, social workers, community health workers, and peer support specialists—work intensively with enrolled members to develop comprehensive care plans that address not only medical and behavioral health needs but also housing, nutrition, income support, legal issues, and other social determinants. For example, an ECM team working with a member experiencing homelessness and managing diabetes might coordinate medical appointments with an endocrinologist and primary care provider, arrange temporary housing through a recuperative care program after a hospitalization, connect the member with a housing navigator to apply for permanent supportive housing, set up insulin storage at a local health center or shelter where the member can safely refrigerate medications, provide medically tailored meals designed for diabetes management, arrange transportation to all medical appointments, and work with a benefits specialist to apply for Social Security disability income. This holistic approach aims to stabilize the member's social situation so that medical treatment can be effective—recognizing that optimal diabetes management is nearly impossible when someone lacks stable housing, reliable food access, or a safe place to store insulin.

Community Supports are evidence-based non-medical services and supports that managed-care plans may offer as alternatives to costlier medical services or institutional care. Unlike ECM, which all plans must provide, Community Supports are optional: each plan decides which services to offer based on local needs and available community resources. The fourteen pre-approved Community Supports categories include housing transition and navigation services (helping members secure and maintain housing); housing deposits, respite, and sustaining services (paying move-in costs or providing short-term financial assistance to prevent eviction); housing modifications and environmental accessibility adaptations (installing grab bars, wheelchair ramps, or air filtration systems); medically tailored meals (home-delivered meals designed for specific conditions like diabetes, renal disease, or heart failure); medical respite care (short-term residential care for homeless individuals too sick to recover on the streets but not sick enough to remain hospitalized); sobering centers (short-term non-clinical support for individuals intoxicated on alcohol or drugs); asthma remediation (environmental assessments and interventions to reduce asthma triggers in the home); and various transportation services beyond what Medi-Cal already covers.

Eligibility for specific Community Supports depends on whether your plan offers that particular service in your county, whether your care team determines the service would help you avoid institutionalization or higher-cost medical care, and whether you meet any service-specific criteria. For example, medically tailored meals might be available only to members with specific diagnoses such as diabetes, congestive heart failure, or chronic kidney disease who have had recent hospitalizations or emergency visits. Housing deposit assistance might require documentation that you are exiting homelessness, leaving an institutional setting, or at imminent risk of eviction. Your care coordinator, primary care provider, or the plan's ECM team assesses your eligibility and helps you access services. To inquire about ECM or Community Supports, contact your plan's member services line and ask whether you qualify for Enhanced Care Management or whether specific Community Supports are available in your county—policies and service availability vary significantly across California's different Medi-Cal managed-care plans and geographic regions, and because these programs are relatively new, implementation remains uneven across the state.

Information Sharing Across Providers and Healthcare Systems

Effective care coordination depends fundamentally on timely, accurate, and comprehensive information flow among all providers, facilities, and organizations involved in your care. Medi-Cal managed-care plans receive electronic data feeds from multiple sources: hospitals submit admission, discharge, and transfer (ADT) notifications alerting the plan when a member enters or leaves an emergency department or inpatient unit; clinical laboratories transmit results for tests ordered by in-network providers; pharmacies report prescription fill dates, medication names, doses, and quantities dispensed; and specialists and ancillary providers submit claims that document services rendered. Plans aggregate this data to create a longitudinal view of each member's healthcare utilization, identify patterns such as frequent emergency visits or medication nonadherence, and trigger outreach from care coordinators when specific clinical events or risk factors are detected.

Many Medi-Cal managed-care plans participate in regional or statewide health information exchanges (HIEs), technology platforms that allow providers in different healthcare organizations to view portions of your electronic medical record with your consent. California's statewide health information exchange infrastructure includes regional exchanges and participation in national networks, enabling a physician in one hospital system to access laboratory results, imaging reports, medication lists, and clinical notes generated by providers in an entirely different system—even a different county or state. This interoperability reduces duplicated testing (you do not need to repeat an expensive MRI you had last month at a different hospital if the new physician can view the images and report electronically), prevents dangerous medication interactions (the emergency physician can see that you recently started a blood thinner, avoiding prescription of drugs that might cause dangerous bleeding), and ensures that urgent findings reach the appropriate physician quickly (an abnormal mammogram result automatically routes to your primary care provider for follow-up rather than sitting unread in a standalone system).

Despite significant technological progress, information gaps persist, particularly when you receive care from out-of-network providers, visit emergency departments or specialists in other counties, or transition between different Medi-Cal managed-care plans. You can help close these gaps by maintaining a personal health record—a simple document, either on paper or in a smartphone notes app, that lists your current medications with doses and frequencies, known drug allergies, major diagnoses (diabetes, heart disease, asthma, mental health conditions), past surgical procedures with approximate dates, recent hospitalizations, and key test results such as your most recent hemoglobin A1c if you have diabetes or your ejection fraction if you have heart failure. Bring this list to every medical appointment, update it whenever medications change or new diagnoses are made, and provide a copy to emergency department staff if you are admitted. When you switch Medi-Cal managed-care plans (during annual open enrollment or following a move to a different county), request complete copies of your medical records from your previous primary care provider and any specialists managing ongoing conditions; you can provide these records to your new providers to ensure continuity of treatment.

If you have concerns about privacy and how widely your health information is shared, federal and state laws including the Health Insurance Portability and Accountability Act (HIPAA) and California's Confidentiality of Medical Information Act (CMIA) strictly regulate who may access your medical records and for what purposes. Providers may access your information through health information exchanges only for treatment, care coordination, or payment purposes—never for marketing or other non-clinical reasons. You have the right under HIPAA to request an accounting of disclosures, a report listing who has accessed your medical record electronically and when. You can request this accounting from your health plan or from any provider who maintains your records. You also have the right to request that certain information be restricted from routine sharing, although providers may override such restrictions in emergency situations where disclosure is necessary to protect your health. Contact your plan's member services department or privacy officer if you have questions about how your information is shared, what security measures protect electronic data, or how to exercise your privacy rights under federal and state law.

Navigating Prior Authorization and Utilization Management

Prior authorization is among the most frequent sources of frustration in managed care, and understanding the process in detail helps you work more effectively with your providers and plan to obtain timely approval for necessary services. When your physician recommends a service, procedure, medication, or durable medical equipment item that requires prior authorization, the physician's office—not you personally—typically initiates the request by submitting clinical documentation to the plan's utilization management department. This submission usually occurs electronically through a web portal or via fax and includes a detailed description of your diagnosis, relevant medical history, prior treatments you have tried and their outcomes, current symptoms and functional limitations, pertinent physical examination findings, laboratory and imaging results, and a clinical rationale explaining why the requested service is medically necessary and meets evidence-based guidelines.

The plan's utilization management staff—often nurses or pharmacists with clinical training—review the request against predetermined criteria, which may include nationally recognized clinical guidelines (such as those published by medical specialty societies), Medi-Cal's coverage policies and benefit definitions, and the plan's own medical necessity criteria. For straightforward requests that clearly meet established criteria, approval may be granted within 24 to 48 hours. More complex requests may require review by a physician advisor, particularly if the requested service falls outside standard guidelines, if prior treatments have not been attempted, or if the clinical documentation is incomplete. California regulations require plans to render a decision on standard prior authorization requests within five business days and expedited requests within 72 hours; if the plan needs additional information from your physician, the clock stops while the plan requests and receives that information, but the total review period including any extensions cannot exceed 14 calendar days for standard requests.

If the plan denies a prior authorization request, the denial notice must be provided in writing and must include specific, clear language explaining the clinical reason for denial, the coverage criteria or guideline that was not met, the evidence reviewed, and detailed instructions for filing an appeal. Your physician can submit additional clinical information, a peer-to-peer consultation request (a phone call between your physician and the plan's reviewing physician to discuss the case), or a formal appeal arguing that the denial was inappropriate. You also have the right to file a member appeal independently, and you can request an expedited appeal if the standard appeal timeframe could seriously jeopardize your health. For denials that are upheld on internal appeal, California law provides an additional layer of review through the Independent Medical Review (IMR) process, administered by the California Department of Managed Health Care or the California Department of Health Care Services depending on your plan type. An IMR involves review by an independent physician expert who is not affiliated with your plan, and the IMR decision is binding on the plan—if the independent reviewer determines the service is medically necessary, your plan must authorize and cover it.

Certain services commonly subject to prior authorization in Medi-Cal managed care include advanced imaging such as MRI, CT, and PET scans (plans want to ensure that less expensive or less invasive tests have been tried first when clinically appropriate); specialty medications, particularly high-cost biologics and brand-name drugs when generic alternatives exist; durable medical equipment such as wheelchairs, hospital beds, and continuous positive airway pressure (CPAP) machines; surgical procedures, particularly elective surgeries or those with significant cost and risk; behavioral health services beyond a limited number of initial visits; home health services; and long-term care including nursing facility placement. For medications, many plans maintain a formulary—a list of preferred medications that are covered without prior authorization or with lower copayments—and require prior authorization or step therapy (trying a preferred medication first) for non-formulary drugs. If your physician believes a non-formulary medication is medically necessary for your specific situation because formulary alternatives have failed, caused intolerable side effects, or are contraindicated due to drug interactions or allergies, the physician can request a formulary exception through the prior authorization process, submitting detailed documentation to support the request.

To minimize delays when you need a service that requires prior authorization, ask your physician's office to submit the request as soon as the decision is made rather than waiting until the day before a scheduled procedure. Provide the office with complete information about previous treatments, other physicians you have seen for the same condition, and any previous imaging or testing, so that the initial authorization request is comprehensive and the plan does not need to request additional records. If your physician's office tells you an authorization was submitted, ask for the prior authorization reference number and write it down; you can use this number when calling the plan to check on the status. If a deadline is approaching—such as a scheduled surgery date or a situation where delayed treatment could cause your condition to worsen—ask your physician to request an expedited review with documentation explaining the urgency. Understanding that prior authorization is a clinical review process, not an arbitrary barrier, helps you advocate effectively: the goal is to provide the plan's reviewers with clear, thorough clinical information demonstrating that the requested service is medically necessary and appropriate for your condition.

Coordination During Care Transitions: Hospital Discharge and Skilled Nursing Placement

Care transitions—when you move from one care setting to another, such as from hospital to home, from emergency department to inpatient unit, from hospital to skilled nursing facility, or from skilled nursing facility back to the community—are high-risk periods for care coordination failures. During transitions, medication lists change, new diagnoses emerge, follow-up appointments must be scheduled, and critical information must transfer from one care team to another. Breakdowns during these transitions frequently lead to hospital readmissions, emergency department visits, medication errors, and worsening of chronic conditions.

When you are discharged from a hospital, the hospital's care team should provide you with written discharge instructions that include your diagnoses, new or changed medications with clear instructions on how to take them, medications you should stop taking, follow-up appointments that need to be scheduled (with timeframes such as 'see your primary care doctor within three to five days'), warning signs that should prompt you to seek immediate medical attention, and any activity restrictions or self-care instructions. The hospital should also send a discharge summary to your primary care provider and to your managed-care plan, typically within 24 to 48 hours, so your ongoing care team knows what happened during the hospitalization and can provide appropriate follow-up. However, these information transfers do not always occur reliably or promptly, creating dangerous gaps.

Medi-Cal managed-care plans receive electronic admission, discharge, and transfer notifications from hospitals, alerting the plan when a member is admitted or discharged. Many plans have care coordinators who specifically focus on hospital discharge and transitional care, reaching out to members within 24 to 72 hours after discharge to ensure you understand your discharge instructions, have obtained any new medications prescribed, have scheduled required follow-up appointments, understand any new medical equipment you need to use at home, and have support for any new self-care tasks such as wound care or blood sugar monitoring. For members with complex needs—such as those experiencing homelessness, those who live alone with limited social support, or those discharged with multiple new medications and complicated self-care requirements—the plan may arrange home health services, medication delivery, telemonitoring, or more intensive care coordination.

If your hospital stay requires follow-up in a skilled nursing facility (SNF) for rehabilitation or continued recovery, the hospital's discharge planning team coordinates with your managed-care plan to arrange SNF placement. The plan must approve the SNF admission, verify that a bed is available at an in-network facility with the appropriate level of care, and authorize an initial length of stay. For members transitioning from SNF back to the community, care coordination is again essential: the SNF should communicate with your primary care provider, reconcile your medication list to reflect any changes made during the SNF stay, schedule follow-up appointments, arrange home health or outpatient therapy if needed, and ensure you have medical equipment and supplies at home. CalAIM's Enhanced Care Management specifically targets members leaving institutional settings, recognizing that the transition from hospital or SNF to the community often fails without intensive coordination and social support.

You can actively participate in safe care transitions by asking questions before you leave the hospital or skilled nursing facility: request a written list of all your medications with doses and instructions; ask what symptoms should prompt you to call your doctor or go to the emergency room; ask who you should call if you have questions after discharge; confirm that follow-up appointments have been scheduled or ask for the phone numbers you should call to schedule them yourself; and request that discharge paperwork be sent to your primary care provider immediately. If you feel you are being discharged before you are ready—for example, if you cannot safely perform activities of daily living at home, if you do not understand how to care for a surgical wound, or if you have no safe place to go after discharge—tell the hospital care team and ask to speak with a social worker or discharge planner. You have the right to appeal a discharge decision you believe is premature, and the hospital must provide you with written information about your appeal rights, known as the Important Message from Medicare for Medicare-Medicaid dual eligible members or similar state-specific notices for Medi-Cal-only members.

Behavioral Health Integration and Substance Use Disorder Treatment Coordination

Mental health conditions and substance use disorders are extraordinarily common among Medi-Cal beneficiaries, and fragmentation between physical health care and behavioral health care has historically produced poor outcomes, missed diagnoses, and inadequate treatment. Medi-Cal managed-care plans coordinate behavioral health services in various ways depending on the county and plan structure: some plans directly manage all behavioral health services (a 'carved-in' model), while other counties maintain separate county-administered mental health plans for specialty mental health services and substance use disorder treatment (a 'carved-out' model). Regardless of structure, effective coordination requires that your primary care provider, behavioral health clinicians, and any specialists involved in your care communicate regularly and share treatment plans.

For mild to moderate depression, anxiety, and adjustment disorders, your primary care provider can often provide initial treatment, including prescribing first-line antidepressant or anti-anxiety medications, delivering brief counseling, and monitoring symptoms over time. Many primary care practices now employ integrated behavioral health clinicians—licensed clinical social workers, psychologists, or marriage and family therapists—who work directly in the primary care office, allowing you to see a behavioral health provider on the same day as your medical appointment and ensuring that the behavioral health clinician and your PCP discuss your care together. This integrated care model, also called collaborative care, is particularly effective for common conditions such as major depressive disorder, generalized anxiety disorder, and panic disorder that occur alongside chronic medical conditions.

For more severe mental illnesses—such as schizophrenia, bipolar disorder, severe major depression with suicidal ideation, or complex post-traumatic stress disorder—specialty mental health services managed by county mental health plans or by your managed-care plan's behavioral health network provide intensive treatment including psychiatry, intensive case management, crisis intervention, medication management, and evidence-based psychotherapies. Accessing specialty mental health services typically requires an assessment to determine medical necessity and eligibility, and your primary care provider or a plan care coordinator can help initiate this referral. Once enrolled in specialty mental health services, coordination between your mental health treatment team and your primary care provider is essential, particularly because psychiatric medications can interact with medications for medical conditions, because serious mental illness increases the risk of diabetes and cardiovascular disease, and because symptoms of mental illness (such as lack of motivation, cognitive difficulties, or paranoia) can interfere with adherence to medical treatment.

Substance use disorder treatment, including medication-assisted treatment (MAT) for opioid use disorder, alcohol use disorder, and tobacco use, is a covered Medi-Cal benefit and is increasingly coordinated with primary care. Many primary care providers can prescribe buprenorphine (Suboxone) for opioid use disorder directly in the primary care office, combining medication with counseling and recovery support services. For members needing higher levels of care—such as residential treatment, intensive outpatient programs, or withdrawal management (detoxification)—the managed-care plan or county behavioral health system coordinates placement, authorization, and follow-up. Because substance use disorders frequently co-occur with mental health conditions and chronic medical problems, care coordination that addresses all three domains simultaneously produces the best outcomes.

If you need behavioral health services, start by talking with your primary care provider, who can provide initial treatment for common conditions, refer you to integrated behavioral health services in the primary care office if available, or help you access specialty mental health or substance use disorder treatment through your plan or county system. If you are in crisis—experiencing suicidal thoughts, severe panic or psychosis, or intoxication requiring medical supervision—call 988 (the national Suicide and Crisis Lifeline), go to the nearest emergency department, or call 911. Crisis stabilization and emergency psychiatric care are always covered without prior authorization. After a psychiatric hospitalization or emergency visit, follow-up coordination is critical: your plan's care coordinator should help you schedule an outpatient psychiatry or therapy appointment within seven days of discharge, ensure you have psychiatric medications, and connect you with ongoing community-based support.

Pediatric and Prenatal Care Coordination

Children and pregnant individuals enrolled in Medi-Cal managed care have specific care coordination needs, and plans must meet enhanced access and quality standards for these populations. For children, well-child visits at recommended intervals—multiple visits during infancy, annual visits during early childhood, and periodic visits during adolescence—form the foundation of preventive care. These visits include developmental screening, immunizations, vision and hearing screening, anemia and lead testing, anticipatory guidance on nutrition and safety, and monitoring of growth and development. Medi-Cal managed-care plans track well-child visit completion rates as a key quality metric, and many plans conduct outreach to families whose children have missed scheduled visits, offering assistance with appointment scheduling, transportation, and addressing barriers to care.

Children with special healthcare needs—including chronic medical conditions such as asthma, diabetes, epilepsy, or congenital heart disease; developmental delays or disabilities; behavioral or mental health conditions; or complex technology dependence requiring home nursing or durable medical equipment—qualify for enhanced care coordination. Plans must offer individualized care plans for these children, coordinate services across multiple specialists (which might include pediatric subspecialists, therapists, educational support, and home health providers), and help families navigate systems that often require extensive parental time and advocacy. California's Children's Medical Services (CMS) program, integrated into Medi-Cal managed care in many counties, provides specialized care coordination for children with qualifying conditions, employing nurses and social workers who understand both medical complexity and family support needs.

For pregnant individuals, comprehensive prenatal care coordination aims to improve birth outcomes and identify complications early. Medi-Cal managed-care plans must ensure access to the first prenatal visit, provide care management for high-risk pregnancies (such as those complicated by diabetes, hypertension, substance use, or prior preterm birth), coordinate referrals to maternal-fetal medicine specialists when indicated, offer childbirth education and breastfeeding support, and ensure postpartum follow-up. Many plans employ perinatal care coordinators—nurses or social workers specializing in pregnancy care—who reach out to newly pregnant members, assess social needs including housing stability and food security, provide education about prenatal testing and healthy pregnancy behaviors, and help navigate the transition to pediatric care for the newborn after delivery. Under CalAIM, pregnant individuals may be eligible for Community Supports such as medically tailored meals, doula services, and housing assistance, recognizing that social determinants profoundly affect pregnancy outcomes.

Immunizations represent a critical coordination point for children's preventive care. Medi-Cal managed-care plans must ensure that children receive all recommended vaccinations on schedule, and California's robust school immunization requirements create strong incentives for families to maintain up-to-date vaccination records. Your child's primary care provider maintains an immunization record and reports vaccinations to the California Immunization Registry (CAIR), a statewide database that tracks all vaccinations administered in California. If your child sees multiple providers or if you move between counties, the CAIR record ensures continuity so vaccines are not unnecessarily repeated or dangerously delayed. When your child starts school or childcare, you will need documentation of immunizations; your primary care provider's office can print an official record from CAIR. If your child has missed vaccines or is behind schedule, the provider can create a catch-up plan to bring immunizations up to date as quickly and safely as recommended by the Advisory Committee on Immunization Practices (ACIP) schedule.

What to Do When Care Coordination Breaks Down

Even well-designed care coordination systems experience failures: referrals are lost or never processed, prior authorizations delay urgently needed care, discharge summaries from the hospital never reach your primary care provider, conflicting medication instructions create confusion and risk, or care coordinators fail to follow up as promised. When you identify a coordination breakdown—such as a specialist appointment that was supposedly scheduled but never confirmed, a medication your hospital discharge papers say to take but your primary care doctor has no record of, or a home health service that was authorized but no agency has contacted you—take immediate action rather than waiting for the problem to resolve itself.

Start by contacting your managed-care plan's member services line, which is required to be available during business hours and often offers 24-hour nurse advice lines for clinical questions. Describe the problem clearly and specifically: state what should have happened, what actually happened (or did not happen), the dates involved, and the names of providers or care coordinators you have spoken with. Ask the member services representative to document the issue, create a case or reference number for tracking, and commit to a specific follow-up timeline—for example, 'We will investigate why the referral was not received and call you back within two business days.' Write down the representative's name, the date and time of your call, and the case or reference number; this documentation becomes important if the problem is not resolved and you need to escalate.

If the problem involves a delay in medically necessary care—such as a denied prior authorization for a service your physician believes you need urgently, a specialist appointment that cannot be scheduled within the required timeframe, or lack of access to a necessary medication—ask to speak with a supervisor or care coordination manager immediately. Explain that the delay is affecting your health and request expedited resolution. For prior authorization denials, ask your physician to submit additional clinical information, request a peer-to-peer review (a phone conversation between your physician and the plan's medical director), or file an expedited appeal if the standard appeal timeline could jeopardize your health. For access problems where the plan cannot provide a service within required timeframes, ask the plan to arrange an out-of-network exception so you can see a provider outside the plan's network at no additional cost to you.

If initial attempts to resolve the problem through member services are unsuccessful, you have the right to file a formal grievance with your managed-care plan. A grievance is a written complaint about any aspect of your care, access, or service that you believe violates your rights or the plan's obligations. Your plan's member handbook, which you received when you enrolled (and which is available on the plan's website), explains the grievance process in detail. Grievances must generally be filed within 180 days of the incident, and the plan must investigate and respond to you in writing within 30 days for standard grievances or 72 hours for expedited grievances involving urgent medical issues. The plan's written response must explain the findings, the resolution offered, and your right to request an Independent Medical Review (IMR) or to file a complaint with state regulators if you disagree with the plan's decision.

For unresolved grievances, denied care you believe is medically necessary, or serious access or quality concerns, you can file a complaint with the California Department of Managed Health Care (for most Medi-Cal managed-care plans) or the California Department of Health Care Services (for certain plan types including COHS plans and some specific behavioral health services). Both agencies operate help centers that can explain your rights, assist with filing complaints, and in some cases intervene directly with your plan to resolve access or care issues. The Department of Managed Health Care's Help Center can be reached by phone and online, and it offers assistance in multiple languages. Filing a state complaint does not prevent you from also pursuing your plan's internal grievance and appeal processes; these are parallel rights, and you can use both. Additionally, legal aid organizations and patient advocacy groups throughout California offer free assistance to Medi-Cal beneficiaries facing coverage denials or access problems; your plan's member services line or your county social services office can provide referrals to these resources.

How This Connects to the Rest of This Series

This guide's account of managed-care coordination assumes and builds on the baseline eligibility and structural context covered in Medi-Cal in plain language (Medi-Cal in Plain Language: Eligibility, Coverage, and the 2026–2028 Changes You Need to Know), and its treatment of Enhanced Care Management and Community Supports is necessarily a summary — Enhanced Care Management, explained (Enhanced Care Management, Explained: Who Qualifies, What the Team Actually Does, and How to Get In) and Community Supports and health-related social needs (Community Supports: The 15 Non-Medical Benefits Medi-Cal Will Now Pay For — and How to Actually Get One), both elsewhere in this series, go into considerably more depth on eligibility criteria, the specific 14-item Community Supports menu, and how to actually request either benefit. This guide's specific contribution is connecting those benefits to the everyday mechanics of referrals, prior authorization, and care transitions that most members interact with far more often than they interact with ECM or Community Supports specifically — and its coverage of behavioral health coordination is a shorter companion to the fuller treatment in behavioral-health care through Medi-Cal (Behavioral-Health Care Through Medi-Cal), also in this series. Reading this guide alongside those companion pieces gives a considerably fuller picture than any one piece alone. How county services and Medi-Cal plans interact (How County Services and Medi-Cal Plans Interact), elsewhere in this series, extends this guide's coordination focus outward to county-administered programs that sit alongside, rather than inside, your managed-care plan. What to do when you cannot find a Medi-Cal specialist (What to Do When You Cannot Find a Medi-Cal Specialist), also in this series, covers the specific escalation path when the referral process this guide describes doesn't produce an actual appointment.

Steps to Use Your Plan's Care Coordination Services Effectively

Know your primary care provider's name, office phone number, and location; establish care with a PCP promptly after enrolling in a plan

Contact your plan's member services line to ask if you qualify for a care coordinator, particularly if you have multiple chronic conditions, recent hospitalizations, or difficulty managing appointments independently

Request prior authorization as early as possible when your physician recommends a service that requires advance approval; ask your doctor's office to submit the request immediately rather than waiting until just before a scheduled procedure

Maintain a current written or digital list of all your medications (including over-the-counter drugs and supplements), allergies, major diagnoses, and recent procedures; bring this list to every medical appointment and update it whenever changes occur

Use your plan's 24-hour nurse advice line for after-hours medical questions that are not emergencies, such as whether a symptom warrants an urgent care visit or can wait until morning

If you experience delays, lost referrals, or conflicting instructions from different providers, call member services immediately and ask for a case number to track the issue

Ask your primary care provider or care coordinator about CalAIM Enhanced Care Management or Community Supports if you face housing instability, food insecurity, difficulty affording utilities, or frequent emergency department visits or hospitalizations

Request written copies of hospital discharge instructions, medication changes, and follow-up appointment recommendations whenever you are discharged from a hospital or emergency department; confirm that this information has been sent to your primary care provider

If you need to change your primary care provider due to relocation, communication difficulties, or preference, contact member services; do not simply stop seeing your current PCP without formally changing your assignment

Review your plan's member handbook (available on the plan website or by requesting a printed copy) to understand specific referral requirements, prior authorization rules, and grievance procedures for your plan

When to Seek Help from Dr. Gill's Practice

If you need a primary care provider within a Medi-Cal managed-care network, contact your plan's member services department to confirm whether Dr. Gill's practice participates in your specific plan and is accepting new patients; plan networks change periodically, and participation varies by plan even within the same county. If you already see Dr. Gill and experience coordination problems—such as delayed specialist referrals, missing prior authorizations, inability to schedule follow-up appointments within required timeframes, or difficulty accessing specialist care—bring these issues to your next appointment or call the office so the care team can advocate on your behalf with your plan, submit additional clinical documentation for prior authorization appeals, or help you navigate the grievance process. The practice can also help you understand complex hospital discharge instructions, reconcile medication lists after hospitalization to identify duplications or dangerous interactions, interpret specialty consultation reports, or connect you with care coordinators if you qualify for enhanced services. For advice about selecting a Medi-Cal managed-care plan during open enrollment or after a change in eligibility category, Dr. Gill can explain how different plans coordinate care, what to consider when comparing provider networks, and which plans offer specific services or Community Supports relevant to your medical and social needs. If you are transitioning from fee-for-service Medi-Cal to managed care or switching between plans, the practice can facilitate medical record transfer and ensure continuity of ongoing treatments and prescriptions during the transition period.

Questions to Ask Your Plan and Care Team

Which medical services and specialists require a referral from my primary care provider before I can schedule an appointment, and which specialists can I access directly without prior approval?

How do I request assignment to a care coordinator, what specific types of assistance can a care coordinator provide, and how often will the coordinator contact me if I enroll?

What is the step-by-step process for prior authorization for procedures, imaging, or medications, how long does approval typically take, and what should I do if my request is denied?

Does my plan offer CalAIM Community Supports such as medically tailored meals, housing transition assistance, environmental home modifications, or transportation beyond standard non-emergency medical transportation, and how do I find out if I am eligible?

How do I change my primary care provider if I move to a different part of the county, if my doctor leaves the network, or if I prefer a different provider for any reason?

What should I do if I receive conflicting medication instructions from my primary care provider and a specialist, or if a hospital discharge plan differs from what my regular doctor recommended?

How can I access my complete medical records from all providers in the plan's network, does my plan participate in a health information exchange that shares records electronically, and how do I control who can view my information?

If I need to file a grievance about a care coordination problem or appeal a denied service, what are the specific steps and deadlines, and can I get help from the plan or an outside advocate with the grievance process?

For members with behavioral health needs: Are mental health and substance use disorder services integrated with my primary care, or do I need to access them through a separate county mental health plan, and how does the plan coordinate between my medical and behavioral health providers?

Takeaway

Medi-Cal managed-care plans coordinate your care by assigning a primary care provider who serves as your central medical home, organizing referrals and specialist services through defined networks and approval processes, offering care coordinators for members with complex medical or social needs, and increasingly connecting medical treatment with community-based supports for housing, nutrition, and other social determinants of health through CalAIM programs. Understanding how your specific plan operates—including which services require referrals or prior authorization, how to access care coordination and Enhanced Care Management, what timeframes apply to specialist appointments and authorization decisions, and what steps to take when coordination breaks down—enables you to navigate the system effectively, obtain timely necessary care, and avoid preventable gaps in treatment. When you encounter coordination problems, delays, or denials that you believe are inappropriate, you have specific rights to file grievances, appeal denials, request expedited reviews for urgent situations, and seek assistance from state regulators and advocacy organizations. Active communication with your primary care provider, proactive use of care coordination resources, and informed self-advocacy are essential tools for making managed care work well for your individual health needs.

General educational information—not medical or legal advice

This guide provides general educational information and is not medical or legal advice. Coverage and procedures vary by plan and circumstance. Urgent or emergency symptoms require appropriate clinical evaluation and should not be delayed while pursuing an administrative remedy.

General educational information—not legal or medical advice

This article provides general educational and policy information. It is not legal advice, medical advice, or a determination that any person or organization has violated the law, and it does not create an attorney-client or physician-patient relationship. Application of the rules depends on current law, governing documents, jurisdiction, chronology, and individual facts. A person facing an active clinical, licensing, credentialing, employment, insurance, or regulatory matter should obtain individualized advice from appropriately qualified professionals.

Sources and Authorities

The sources below are provided so readers can confirm the governing text and current agency guidance. Laws, regulations, agency pages, and implementation dates can change; time-sensitive requirements should be checked against the current official source.

DHCS — Medi-Cal — dhcs.ca.gov

DHCS — Medi-Cal Changes — dhcs.ca.gov

DHCS — Enhanced Care Management and Community Supports — dhcs.ca.gov

DHCS — Medi-Cal Transportation Services — dhcs.ca.gov

California DMHC — File a Complaint — dmhc.ca.gov