Medi-Cal Services

Medi-Cal pays for a wide variety of medical expenses:

Depending on how you qualify for Medi-Cal, the program may pay for all of these services (full-scope Medi-Cal) or just some of them (partial-scope Medi-Cal).

Like other health coverage plans, Medi-Cal has rules about what it will cover. For example, Medi-Cal only pays for prescriptions that are on its list of accepted drugs. Along the same lines, it may refuse to pay for certain procedures like cosmetic surgery, and it will require that you get prior authorization for some services. If Medi-Cal decides not to pay for something and you think it should, you can appeal the decision.

If you have Medi-Cal and another health insurance policy, Medi-Cal will generally require that the other policy be billed first. This is why Medi-Cal is known as the “payer of last resort”.

Getting Medi-Cal – Eligibility Categories and Application

You can think of Medi-Cal as a single program that you can qualify for in many different ways. These different ways are called eligibility categories. For example, SSI-Linked Medi-Cal is an eligibility category that allows people who qualify for SSI to automatically get Medi-Cal. There are over 90 eligibility categories, each with its own rules and requirements. Once you meet the requirements of an eligibility category, you are eligible for either full or partial-scope Medi-Cal.

Db101 describes the four eligibility categories that people with disabilities most often use:

You don’t need to do anything extra to get SSI-Linked Medi-Cal. Just apply for SSI by calling 1-800-772-1213 (voice), 1-800-325-0778 (TTY) or by visiting your local Social Security office. You can apply for the other categories at your local county welfare office. Also, there are Medi-Cal eligibility workers at many hospitals and clinics who can process applications.

Medi-Cal Eligibility Categories

SSI-Linked Medi-Cal

One way to get Medi-Cal is by qualifying for an SSI benefit. SSI is a federal program for people with low income who are aged, blind, or disabled. To receive a benefit, you must:

1. Meet Social Security’s definition of disability, blindness, or age (65+).
2. Not be doing Substantial Gainful Activity. This means that your gross earnings are less than a certain amount of money each month. For 2008, the limit is $940 ($1,570 for the blind).
3. Have less than $2,000 in assets ($3,000 for a couple). SSA does not count all of your assets. Click here for a list of exemptions.
4. Have Total Countable Income that is less than the SSI/SSP maximum benefit amount. For 2008, that monthly amount is $870 for a disabled individual living independently ($1,524 for a couple in the same situation). Maximum benefit amounts vary based upon your living situation and disability. Click here for a chart detailing all of the payment standards.

For this final requirement, SSI uses a calculation to figure out how much of your income to count.

Step 1: If you have monthly unearned income (for example, an SSDI benefit, a pension, dividends), subtract a $20 "General Income Exclusion" from it to calculate your countable unearned income. If you do not have unearned income, this exclusion is applied to any earned income.

Countable Unearned Income Calculation

		Monthly Unearned Income
	-	$20 General Income Exclusion
	=	Countable Unearned Income

Step 2: If you have monthly earned income (for example, wages), subtract a $65 "Earned Income Exclusion" from it (along with the remainder of the $20 "General Income Exclusion" that you have not applied to Unearned Income), along with any Impairment Related Work Expenses, and divide the resulting figure by two to find your countable earned income. If you have Blind Work Expenses, subtract them after you divide.

Countable Earned Income Calculation

		Monthly Earned Income
	-	$65 Earned Income Exclusion
	-	$20 General Income Exclusion (only if you haven't already applied it to unearned income)
	-	Impairment Related Work Expenses
	÷	2
	-	Any Blind Work Expenses
	=	Countable Earned Income

Step 3: Add your countable unearned income to your countable earned income to find your total countable income.

Total Countable Income Calculation

		Countable Unearned Income
	+	Countable Earned Income
	=	Total Countable Income

*If you are married, SSA may add your spouse’s income and assets to yours. This is a process called deeming.

SSA will review your application to see if you meet the income, asset, and disability requirements. If you do, you will receive an SSI benefit check. When you qualify for SSI, you automatically get Medi-Cal. SSA reports your Medi-Cal eligibility to the local county welfare office, so you do not need to apply for Medi-Cal separately. Your Medi-Cal coverage begins the same month that your SSI benefit begins. If you qualify for Medi-Cal through your SSI eligibility, you will receive free, full-scope Medi-Cal coverage. For more information on the SSI program, see DB101’s SSI program description.

Aged & Disabled Federal Poverty Level Medi-Cal

If you are aged or disabled, and are not eligible for SSI, you may be able to get Medi-Cal through the Aged & Disabled Federal Poverty Level (A & D FPL) program. You must:

1. Be either aged (65+), or disabled (meet Social Security’s definition of disability, even if your disability is blindness)
2. Have less than $2,000 in assets ($3,000 for a couple). Like SSI, this program does not count all of your assets. Click here for a list of exemptions.
3. Through 3/31/2009, have less than $1,097 in countable monthly income for an individual ($1,524 through 9/30/2008 for a couple).

The rules for counting income are similar to those used for the SSI program, with a few additional deductions:

First, find your total countable income using Social Security’s rules (see above).

Next, take the number of people in your household who are not applying for the A&D FPL program, and use it to figure out your Maintenance Needs Allowance. Subtract this amount from your total countable income:

*adapted from HCA

Then, subtract any health insurance premiums that you pay. These include Medicare, health, vision, and dental insurance premiums.

Finally, if you are living in a board and care facility, subtract $315.

The number you get is the amount of monthly income that is counted for the A & D FPL program. If it is less than $1,097 for individuals or $1,524 for a couple, then you are eligible for free, full scope Medi-Cal.

California’s 250% Working Disabled Program

If you are working, disabled, and your income is too high to qualify for free Medi-Cal, the California 250% Working Disabled (250% CWD) Program may allow you to get Medi-Cal by paying a small monthly premium. To qualify, you must

1. Meet the medical requirements of Social Security’s definition of disability. You don't have to meet the income and work requirements.
2. Be working and earning income. The Medi-Cal regulations do not define what “working” means for this program, and you can qualify if you are working part time. You can use pay-stubs or other written verification from an employer to prove that you’re working.
3. Have assets worth less than $2,000 for an individual ($3,000 for a couple). The same asset exclusions apply for this program as the ones mentioned above. Additionally, retirement funds like 401(k)’s are not counted as assets for this program.
4. Have countable income less than 250% of the Federal Poverty Level. There is one major difference in the income calculations from those described above. Disability income does not count for the 250% CWD program. This means that SSDI, Worker’s Compensation, California State Disability Insurance, and any federal, state, or private disability benefits are not considered as income for this program.
5. Have countable unearned income less than the appropriate SSI/SSP benefit rate. Again, disability income doesn't count.

Through 3/31/2009, the monthly countable income limits for this program are $2,167 for individuals and $2,917 for couples. These figures are calculated by taking the yearly FPL ($10,400 for individuals, $14,000 for couples), dividing them by 12, multiplying that figure by 2.5, and then rounding up to the nearest dollar.

Keep in mind that these are countable income limits, which is your gross income minus certain deductions. Your gross income can be much higher than your countable income. For example, an individual with no unearned income or IRWEs can make $53,028 a year in gross income and still be eligible for this program.

The premium you pay depends on your countable income:

* Adapted from HCA

The Medi-Cal Third Party Liability Branch will bill you for this premium on the 23^rd of each month. Once you pay the monthly premium, you will receive full-scope Medi-Cal.

For more information on use of the 250% California Working Disabled Program in your area, contact your county coordinator for the program.

Aged, Blind, & Disabled Medically Needy Medi-Cal

If you cannot qualify for free Medi-Cal or the 250% CWD program, you may be able to get Medi-Cal through the Aged, Blind, & Disabled - Medically Needy (ABD – MN) program, but you may have to pay a share of cost. A share of cost is a certain amount of money you must spend on medical care each month before Medi-Cal begins to pay for services. To qualify for the program, you must:

1. Meet Social Security’s requirements for age, blindness, or disability.
2. Meet the Medically Needy program’s property requirements. These requirements depend on your family size:

*From HCA

To find out how much your share of cost will be:

First, find your total countable income using SSA rules (see above).

Next, Subtract the Maintenance Needs Level for your family size. (For this program, you include yourself in the family. So, if you have a spouse and 2 children, your family size is 4.)

Finally, subtract any health, vision, and dental insurance premium payments.

* From HCA

The resulting figure is your share of cost for that month. If you get a number that is 0 or less, then you have no share of cost for that month. For example, if you’re living alone and have $800 in countable income, your share of cost for that month is $800 - $600 = $200. You will only have a share of cost in the months when you have medical services.

HCA publishes fact sheets that are county specific and translated into a variety of languages on ways to spend your share of cost.

Eligibility Categories Summary

SSI-Linked
	Must Meet SSI's definition of:	Age, blindness, or disability
	Income Limits:	Gross Income Less than SGA ($940 for individual, $1,570 if blind). Countable income less than the SSI/SSP benefit amount for your living situation
	How Income is Counted:	SSI's countable income calculation
	Countable Assets Limits:	Up to $2,000 for individual, $3,000 for couples
	Cost of Benefit:	Free
	Benefit:	Full-scope Medi-Cal
Aged & Disabled Federal Poverty Level
	Must Meet SSI's definition of:	Age or disability
	Income Limits:	Countable Income less than $1,097 for individual, $1,524 for couples
	How Income is Counted:	SSI's countable income calculation - MNA for number of household members not applying – health, vision, and dental insurance premiums
	Countable Assets Limits:	Up to $2,000 for Individual, $3,000 for couples
	Cost of Benefit:	Free
	Benefit:	Full-scope Medi-Cal
250% California Working Disabled
	Must Meet SSI's definition of:	Disability
	Income Limits:	Countable Income less than 250% of the Federal Poverty Level ($2,167 per month for individuals, $2,917 for couples)
	How Income is Counted:	SSI's countable income calculation, but any disability income is not considered income
	Countable Assets Limits:	Up to $2,000 for Individual, $3,000 for couples; money in retirement accounts is not considered as an asset
	Cost of Benefit:	Sliding scale premium
	Benefit:	Full-scope Medi-Cal
Aged, Blind & Disabled - Medically Needy
	Must Meet SSI's definition of:	Age, blindness, or disability
	Income Limits:	No income limit, but your countable income determines your share of cost
	How Income is Counted:	SSI's countable income calculation - MNA for number of people in household, including the applicant – health, vision, and dental insurance premiums
	Countable Assets Limits:	Up to $2,000 for individuals, $3,000 for couples, with an additional $150 per additional family member
	Cost of Benefit:	Share of cost
	Benefit:	Full-scope Medi-Cal

It is important to remember that these are just 4 of the many ways to get Medi-Cal. To learn about other eligibility categories, you can visit a benefits planner or talk to a Medi-Cal eligibility worker.

Keeping Your Medi-Cal

Medi-Cal eligibility categories have complicated rules for how much money you can earn. So, when your income changes, it may affect your eligibility for Medi-Cal coverage. There are, however, a number of programs designed to help you keep your coverage when your income goes up.

250% California Working Disabled Program

If you’re receiving free Medi-Cal and your income goes up because you are working, you may be eligible to switch to the 250% CWD program. Medi-Cal workers are required to automatically check to see if you are eligible for this program when your income disqualifies you from your eligibility category. If they don’t, you should ask them to. You’ll have to begin paying for your Medi-Cal coverage, but the amount is small compared to the income you’re earning. See above for a description of this program.

SSI’s 1619(b) Provisions

If you’re on SSI-Linked Medi-Cal, and then your SSI benefit goes to zero because you go back to work, a section of the SSI regulations called the 1619(b) provisions allow you to keep your Medi-Cal coverage. In order to continue your Medi-Cal coverage under this program, you must:

• Have been eligible for an SSI cash payment for at least 1 month
• Still meet SSI requirements, like disability, blindness, or age, that don’t have to do with income
• Need Medi-Cal coverage to continue working, and
• Have less than $34,346 in gross earnings ($35,906, if blind) or have high medical expenses that will be evaluated on a case by case basis. Note that this program does not use the countable income calculation.

The $34,346 income limit is called a threshold amount. This is what Social Security calculates as the value of your SSI and Medi-Cal benefits. They determine this based on the SSI benefit in California, along with averages of medical costs in the state. So, if you’re earning enough money to replace the benefits and cover your medical costs without help from the government, then you’re usually not eligible for the program.

If your expenses are higher than the state average, Social Security may increase the threshold on case-by-case basis. If you have IRWEs, BWEs, are contributing to a PASS, have a publicly funded personal assistant, or have medical expenses higher than the state average, you may be eligible for an individual threshold amount.

Pickle Amendment

When calculating your countable income, SSI considers any SSDI benefits as unearned income. SSDI benefits increase every year to cover cost of living increases. This increase may be enough to make you ineligible for SSI, and the Medi-Cal linked to it. The Pickle Amendment protects Medi-Cal coverage for people in this situation. In other words, if you lose your SSI benefit because of a cost of living increase in your SSDI benefit, you can keep your Medi-Cal.

For more information, see Health Consumer Alliance’s excellent pamphlet on the Pickle Amendment.

Other Medi-Cal services

Besides health care services, Medi-Cal also pays for health insurance premiums in certain circumstances. There are a number of premium payment programs, organized into the following 2 categories:

Medicare Savings Programs

There are four programs that have Medi-Cal pay for Medicare premiums, co-payments, or deductibles. These programs are known as Medicare Savings Programs or Medicare Buy-Ins.

Each program has specific income limits and pays for different Medicare costs:

The Qualified Medicare Beneficiary (QMB) program pays for Medicare Part A and Part B premiums, coinsurance and deductibles. To qualify, an individual must:

• Be eligible for Medicare Part A and Part B
• Have countable income at or below 100% of the Federal Poverty Level ($867 per month through 3/31/2009, $1,167 for couples)
• Have assets at or below the limit ($4,000 for individuals, $6,000 for couples)
• Meet Medi-Cal requirements besides income and assets limits

This program does not apply benefits retroactively.

The Specified Low-Income Medicare Beneficiary (SLMB) program pays for Medicare Part B premiums. To qualify, an individual must:

• Be eligible for Medicare Part A and Part B,
• Have countable income less than 120% of the Federal Poverty Level ($1,040 per month, $1,400 for couples through 3/31/2009)
• Have assets at or below the limit ($4,000 for individuals, $6,000 for couples)
• Meet Medi-Cal requirements besides income and assets limits

The Qualified Invidiual-1 (QI-1) program pays for Medicare Part B premiums. To qualify, an individual must:

• Be eligible for Medicare Part B
• Have countable income between 120% and 135% of the Federal Poverty Level (through 6/30/2008, between $1,040 and $1,170 per month for individuals, and between $1,400 and $1,575 for couples)
• Have assets at or below the limit ($4,000 for individuals, $6,000 for couples)
• Meet Medi-Cal requirements besides income and assets limits

The Qualified Disabled Working Individual (QDWI) program pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their SSDI and Medicare benefits due to earnings above the SGA amount. To qualify, an individual must:

• Be less than 65 years old
• Still be disabled
• Still be eligible for Medicare under a work incentive program
• Have income at or below 200% of the Federal Poverty Level (through 3/31/2009, $1,734 per month for individuals, $2,282 for couples)
• Have assets at or below the limit ($4,000 for individuals, $6,000 for couples)
• Not be eligible for Medi-Cal

SSDI has rules that encourage you to return to work. After your SSDI benefit ends, you will still receive free Medicare benefits for 93 months. After that period ends, you may want to consider the QDWI program.

Medi-Cal’s Health Insurance Premium Payment (Medi-Cal/HIPP)

There are certain situations when Medi-Cal will pay for private health insurance premiums. This program is for people who:

• Are on Medi-Cal,
• Also have private health insurance, or have private coverage available,
• Have a high cost medical condition, AND
• Have lost (or are about to lose) private coverage

The idea is that when you lose your private insurance, Medi-Cal can either pay for your medical expenses or pay for you to keep your private coverage. Medi-Cal will do whichever costs less. If you currently have private health insurance, the program is called Health Insurance Premium Payment (HIPP). If you have private coverage available, but aren’t using it, the program is called Employer Group Health Plan (EGHP). Besides the difference in names, the programs are otherwise identical and are usually simply referred to as Medi-Cal/HIPP.

To qualify for the Medi-Cal/HIPP program, you must:

• Be on Medi-Cal
• Have no share of cost, or have one that is $200 or less
• Have a high cost medical condition. This means that the average Medi-Cal costs for treating your condition are more than twice the cost of the monthly premium
• For example, your premium is $100 and your costs for treatment are $200
• Have available, or be currently using, group health coverage, COBRA, or a conversion policy. A conversion policy is one where you converted a private group policy into a private individual policy
• Apply for Medi-Cal/HIPP within 30 days of your coverage ending (20 if you’re using a conversion policy)
• Have a policy that covers your high cost medical condition
• Not part of a pre-paid or county health plan (County Health Initiative, Geographic Managed Care, County Medical Services Program)
• Not be covered through the MRMIB program

Medi-Cal should evaluate your eligibility for Medi-Cal/HIPP when you indicate that you have insurance available but haven’t applied for it, that you are about to end your health insurance, or that your policy has lapsed. To apply, you’ll need to provide forms from your insurance company describing your benefit and a diagnosis signed by your doctor.

If you are eligible for Medi-Cal/HIPP, you will still be on Medi-Cal. The only change will be for those who did not previously have private coverage. If that’s the case, Medi-Cal will become the payer of last resort. If you are accepted into the Medi-Cal/HIPP program you must participate or else you can lose your Medi-Cal eligibility. Your eligibility for the program is reevaluated every year.

Other Information

Some examples of high cost medical conditions are AIDS, asthma, cancer, diabetes, heart disease, paralysis, and pregnancy. There are many others, and Medi-Cal evaluates applications on a case-by-case basis.

Medi-Cal/HIPP will not pay for past premiums.

Medi-Cal/HIPP will pay for family members who aren’t on Medi-Cal when it will save money for the state. For example, let’s say that you have private health coverage that also covers your family members. You are not on Medi-Cal, but your family members are. If it saves the state money, Medi-Cal/HIPP will pay for your premiums so that your family members can be on the private policy.

Sources

The following links are provided for those who want detailed information on Medi-Cal. For those looking for more general information, please go to DB101’s Medi-Cal Resources page.

The California Department of Health Care Services publishes their All County Welfare Directors Letters online. They are organized by year and by topic. Note that many of the Medi-Cal programs addressed on this site are found under the “Disability” heading.

The Los Angeles Department of Public Social Services publishes their Medi-Cal Policy guide online.

The Health Consumer Alliance (HCA) publishes brochures on Medi-Cal. These are excellent resources for learning about Medi-Cal programs, and provided source material for parts of this page.

HCA and Protection and Advocacy, Inc. publish an “Overview of the Medi-Cal System”. This document includes references to laws, regulations and court decisions on Medicaid and Medi-Cal.