PURPOSE

This program allows disabled workers to buy into Medi-Cal health coverage by paying a monthly premium.

HISTORY

This is an expansion of the federal Medicaid program authorized by the Federal Balanced Budget Act of 1997. California's AB 155 (sponsored by Assemblywoman Migden) authorized this new Medi-Cal category. This program took effect April 1, 2000.

ELIGIBILITY

An individual must be working, meet Social Security’s medical definition of disability, and meet the program’s asset and income requirements.

Workers not enrolled in any disability benefits program may be eligible for this program if they meet the medical definition of disability.

Work activity is not considered in the medical definition of disability in this Medi-Cal category.

Working disabled individuals who do receive disability income, such as Social Security Disability Insurance (SSDI) or State Disability Insurance (SDI), may also be eligible for this program.

Important: Medi-Cal’s deeming rules apply when a worker has combined household income, for example income from a spouse.

FINANCIAL ELIGIBILITY

Asset Requirements

An individual may not have liquid assets (accessible money) in excess of $2,000 ($3,000 for a couple). Ownership of one house, occupied by the individual, and one car will not be considered when determining the individual’s resource levels.

Note: This Medi-Cal category exempts (does not consider) all Internal Revenue Service (IRS) approved retirement accounts, such as employer sponsored 401k, 403b accounts, or individual retirement accounts (IRAs) authorized in the IRS codes.

Income and Earnings Rules

The program uses Medi-Cal’s countable income calculation to determine a worker’s financial eligibility and the program’s monthly premium. Note that a worker's disability income is not counted for this program. For example, disability cash benefits from State Disability Insurance, Short Term Disability, SSI, SSDI, Workers' Compensation, or Long Term Disability Insurance is NOT counted in this program.

An individual can have a total of $2,042 of total countable income in 2006 to be eligible for this program. This figure is the monthly 2006 Federal Poverty Level ($817) times 2.5. If an individual has no unearned income, they can earn up to $4,169 a month ($50,028 annually) and still be eligible for this program.

Note: This Medi-Cal program only considers the Federal Poverty Level for individuals and married couples when determining eligibility and premium costs.

Medi-Cal’s deeming rules apply when a worker has a combined household income, including, for example, income from a spouse.

Individuals age 65 or older who are currently working may also be eligible for this program. At age 65, SSDI and SSI turn into retirement benefits that are not exempted from unearned income requirements. Social Security retirement benefits will count as income and may make an individual ineligible for the 250% California Working Disabled Program.

RESIDENCY REQUIREMENT

An individual must be a legal United States and California resident. Current provisions regarding immigrants can be found in the federal Welfare Reform Act.

The Supplemental Security Income (SSI) program provides an explanation of the rules on the Social Security Admninistration's website.

Another source of information for immigrants and Social Security can be found on the People's Guide.

BENEFIT

This eligibility category of Medi-Cal coverage allows the recipient to participate in full-scope Medi-Cal and access additional Medi-Cal programs such as:

• Medi-Cal’s Health Insurance Premium Payment program (Medi-Cal/HIPP);
• Medi-Cal’s Medicare premium payment programs for Qualified Medicare Beneficiaries (QMB); and
• In-Home Supportive Services (IHSS), if found eligible for these services by means of a needs assessment.

The Centers for Medicare and Medicaid Services (CMS) provides an explanation of many of the services covered by full-Scope Medi-Cal (Medicaid) on its website under the heading of Scope of Medicaid Services.

APPLICATION

Processing of an application takes an average of between 30 to 90 days. The individual is mailed monthly premium invoice forms 90 days after application.

An eligibility worker may enroll an individual immediately without conducting a medical determination of disability if the individual already has met the medical rules for disability. For example, a Social Security Disability Insurance (SSDI) beneficiary has already met the medical rules for this program. The premium invoices may take approximately 90 days to be sent.

Premiums for this program are payable from first month of enrollment.

Information regarding local Medi-Cal offices and telephone numbers can be obtained on the California Department of Health Care Services website or by calling the Beneficiary Unit for Medi-Cal, 916-636-1980.

PREMIUM

The Third Party Liability Branch of Medi-Cal bills the individual for the premium on the 23^rd of each month.

Premiums paid are based on monthly Total Countable Income (see above).

Premiums may increase or decrease according to changes in the individual’s earnings. The exception is when a worker has combined household income with others. Medi-Cal’s deeming rules apply in this situation.

The Premium Table below shows the range of monthly premiums from $20 to $200 for an individual, and from $30 to $375 for a couple.

ADDITIONAL INFORMATION

This program may be a more cost effective eligibility category of Medi-Cal for working disabled individuals. This is especially true when an individual’s income, after the countable income calculation:

• Disqualifies the individual from continuing on Aged and Disabled Medi-Cal; and/or
• Adds to a share-of-cost in Medically Needy Medi-Cal.

For a chart of the current year’s Federal Poverty Levels provided by the U.S. Department of Health and Human Services (HHS), consult the HHS website.

Since this is considered a new California Medi-Cal program, some county offices may not be familiar with all its provisions.

Note: Note that the individual's SSDI benefit does not count towards unearned income in this program. Looking at the Premium Table, this person will pay $75 a month in monthly premiums.