legalizeMJ
9 months ago
3/17/2014 Medi-cal (For people with Medicare)
Medi-Cal, the Medicaid program in California, provides health coverage to people of any age who meet certain income eligibility requirements. While there are several ways to qualify for Medi-Cal, this section focuses only on Medi-Cal beneficiaries who also qualify for Medicare — individuals who are over a certain age and/or disabled. People who qualify for both Medicare and full Medi-Cal are known as “dual eligibles” or “Medi-Medis.”
Topics On This Page
What Medi-Cal Covers
Prescription Drugs
Cal MediConnect
How to Qualify
Medi-Cal Programs
Supplemental Security Income (SSI)
Aged & Disabled Federal Poverty Level (A&D FPL) Program
Medi-Cal with a Share of Cost (SOC)
250% California Working Disabled (CWD) Program
How to Apply
1. What Medi-Cal Covers
Medi-Cal pays for “medically necessary” health care such as:
Physician visits
X-ray and laboratory tests
Hospital and nursing-home care
Home health care
Certain prescription drugs excluded as a Medicare Part D benefit
Prosthetic and orthopedic devices
Hearing aids
Medical equipment
Ambulance services
Hospice care
Dental services through its Denti-Cal program
Medi-Cal will only cover these costs and services if you use providers that accept Medi-Cal. If you have both Medicare and Medi-Cal, Medicare is the primary payer (meaning Medicare will pay first for Medicare-covered benefits) and Medi-Cal is the secondary payer. If you qualify for full Medi-Cal (Medi-Cal without a share of cost (SOC)), Medi-Cal will also cover your Medicare Part A and B deductibles and copayments, and pay your monthly Medicare Part B premium. Learn more.
If you have both Medicare and Medi-Cal, how you receive your benefits depends on what coverage option you choose for your Medicare.
For Medicare benefits, you may choose fee-for-service Original Medicare in all counties, or a Medicare Advantage (MA) plan, if available in your county. If you choose an MA plan, the MA plan that works best for people with both Medicare and Medi-Cal is the Special Needs Plan (SNP) for dual eligibles or D-SNP. If you’re enrolled in a D-SNP, you do not have copays, coinsurance or premiums associated with other types of MA plans. For more information on MA plans, see our Medicare Advantage section.
For Medi-Cal benefits, as of January 1, 2023, you must join a Medi-Cal managed care plan if you do not have a share of cost. This change is due to the Department of Health Care Services’ (DHCS) multi-year project, CalAIM (California Advancing and Innovating Medi-Cal).
Some exceptions include people with Medicare and Medi-Cal who have a share of cost living in the community (versus a Skilled Nursing Facility), those enrolled in a SCAN health plan, Program of All Inclusive Care for the Elderly (PACE) enrollees, residents of California veteran homes, and Native Americans who chose fee-for-service Medi-Cal.
If you fall into one of these exceptions, you can choose fee-for-service Medicare and Medi-Cal. Make sure your doctor or hospital accepts Medi-Cal as well as Medicare. Present both your Medicare card and your Medi-Cal Benefits Identification Card (BIC) to your doctors and other providers when receiving services, so that they can bill Medicare and Medi-Cal directly.
If you enroll in a Medicare Advantage plan, you must see doctors and other providers in the plan’s network, except for emergency and urgent care. Make sure any doctors you want to continue seeing are in that plan’s network. See DHCS fact sheets, Medicare Medi-Cal Plans: Information for Providers and The Facts on Balance Billing.
Note
Note: If you live in one of the following seven counties (Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo or Santa Clara), you should have been automatically enrolled into an Exclusively Aligned Enrollment Dual Special Needs Plan (EAE D-SNP). These plans are operated by the same parent company as the former Cal MediConnect plans that ended December 31, 2022. These plans are also referred to as Medicare Medi-Cal Plans or MediMedi Plans (MMPs). For more information, see the Department of Health Care Services’ webpage: Cal MediConnect
Transition – Information for Beneficiaries webpage. Also see DHSC’s webpage, Dual Special Needs Plans (D-SNP) Contract & Program Guide.
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2. Prescription Drugs
If you are receiving both Medicare and Medi-Cal benefits, the Medicare Part D drug benefit will provide your prescription-drug coverage instead of Medi-Cal. You must be enrolled in a Medicare Part D drug plan or a Medicare Advantage prescription drug plan to get these benefits. Medi-Cal, however, will pay for certain categories of drugs not covered by Part D, including:
Drugs used for smoking cessation
Certain cough and cold drugs
Certain over-the-counter drugs
Vitamins and minerals
Medi-Cal will pay for these drugs through your respective Medi-Cal managed care plan.
If you are exempt from the mandatory enrollment in a Medi-Cal managed care plan and opt for fee-for-service Medi-Cal, you will continue to receive your Medi-Cal covered drugs through the MediCal Rx program, which started January 1, 2022. Call the Medi-Cal Rx Call Center Line at 1-800-977-2273 or visit medi-calrx.dhcs.ca.gov/ for more information.
With Medicare Part D drug coverage, you must make copayments of no more than $1.55 for generic drugs and $11.20 brand name drugs in 2024. The Low-Income Subsidy (LIS) program, also known as the “Extra Help” program, will pay for part or all Medicare Part D drug-benefit plan premiums, depending on the plan in which you are enrolled. Learn more about the Extra Help program and the Medicare Part D drug benefit.
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3. How To Qualify
To find out if you qualify for one of Medi-Cal’s programs, look at your countable monthly income. As of January 1, 2024, there is no longer an asset limit for all the Medi-Cal programs listed below, except for Supplemental Security Income (SSI). For SSI, the asset levels are $2,000 for an individual and $3,000 for a couple.
Your income determines the Medi-Cal program for which you qualify. See next section.
Medi-Cal Programs – Qualification At A Glance – 2024
Asset limits are eliminated for all programs except SSI as of January 1, 2024.
SSI asset limits are:
Single: $2,000; Couple: $3,000
Program / Requirements Your Monthly Income
Supplemental Security Income (SSI)
65 or older, blind or disabled
Single: up to $1,182.94/mo.
Couple: up to $2,022.83/mo. Note: Higher income levels apply for individuals who are blind.
Aged & Disabled Federal Poverty Level (A&D FPL) Program
65 or older, blind or disabled
Single: up to $1,732/mo.
Couple: up to $2,351/mo.
Medi-Cal with a Share of Cost (SOC)
65 or older, blind or disabled
Single: over $1,732/mo.
Couple: over $2,351/mo.
250% California Working Disabled (CWD)
Have work
Meet Social Security’s definition of disability
Pay $0 monthly premium
as of July 1, 2022
Single: up to $3,138/mo.
Couple: up to $4,260/mo. Note: Income excludes disability benefits
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5. Medi-Cal Programs
Supplemental Security Income (SSI)
If you qualify for Supplemental Security Income (SSI), you automatically qualify for full Medi-Cal coverage. To qualify for SSI, you must be age 65 or older, blind or disabled. Your countable monthly income may not exceed $1,182.94 for an individual or $2,022.83 for a couple (higher income levels apply for individuals who are blind). And your assets may not exceed $2,000 for an individual and $3,000 for a couple.
Aged & Disabled Federal Poverty Level (A&D FPL) Program
If you are aged (65+) or disabled and are not eligible for the SSI program, you may be able to get Medi-Cal through the Aged & Disabled Federal Poverty Level (A&D FPL) program. To qualify, you must:
Be aged (65+) or disabled (meet Social Security’s definition of disability, even if your disability is blindness).
Have less than $1,752 in countable monthly income for an individual ($2,371 for a couple). These figures include the $20 disregard. For more information, see our Medi-Cal Programs – Qualification at a Glance chart (above).
This Medi-Cal program uses SSI countable income rules as well as a few extra rules you should know. For more information, visit the Medi-Cal section of the Disability Benefits 101 website.
Medi-Cal With A Share Of Cost (SOC)
If your monthly income is higher than the limits to qualify for SSI or the A&D FPL program (see above), you may still be eligible for Medi-Cal with a share of cost (SOC). An SOC functions like a deductible. You must pay this amount in any month you incur medical costs. After your SOC is paid, Medi-Cal will pay the remaining amount of your medical bills for that month.
Note: A SOC is not a monthly premium. It is more like a deductible. It is the amount of medical expenses you are responsible to pay for before you can get full Medi-Cal coverage for the remainder of the month. If you have no medical expenses, you pay nothing.
Your SOC is determined according to your monthly income, using the following formula: Medi-Cal subtracts $600 (for an individual) or $934 (for a couple) from your monthly income, and any other health-insurance premiums you may be paying.
For example, if you have an individual monthly income of $1,600, Medi-Cal subtracts $600 for a SOC of $1,000. This means you must pay at least $1,000 in covered medical expenses and/or health care premiums in a given month before Medi-Cal covers any of your health care costs for that month. For people with a high SOC, Medi-Cal is mostly a form of catastrophic coverage, meaning Medi-Cal will most likely only help them for emergencies or high-cost medical conditions.
Note: If you have Medi-Cal with a SOC, Medi-Cal will not pay your Medicare Part B monthly premium. This means your Part B premium will be deducted from your Social Security check each month. One exception applies if you are in a Medicare Savings Program (MSP) that pays for your Part B premium (QMB, SLMB or QI). If you are in one of these MSPs, you will not be affected.
If you meet your SOC with medical costs in any given month, Medi-Cal will retroactively pay your Part B premiums for the month(s) in which the SOC is met. Medi-Cal will send the payment to the Social Security Administration (SSA), which will refund you the amount of the premium. Any Part B premium refund received from the SSA will be counted as a resource, not income, in the month you receive it.
250% California Working Disabled (CWD) Program
The 250% California Working Disabled (CWD) program helps Californians who are working and disabled. If eligible, as of July 1, 2022 a California law allows you to receive full Medi-Cal coverage with $0 monthly premium.
To qualify, you must:
Meet the medical requirements of Social Security’s definition of disability.
Be working and earning income (this can be part-time work).
Have countable income less than 250% of the federal poverty level (in 2024, this equates to $3,158/mo. for individuals or $4,280/mo. for couples; these figures include the $20 disregard). Disability income does not count toward the limit, including:
Social Security Disability Insurance (SSDI)
Worker’s Compensation
California State Disability Insurance (CSDI)
Federal, state and private disability benefits
Also learn about how AB 1269 made the California Working Disabled program event better. This bill was signed into law in 2009 and became effective August 2011.
All these CWD rules are explained in more detail in the Medi-Cal section of the Disability Benefits 101 website.
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6. How To Apply
When you apply and qualify for Supplemental Security Income (SSI) at your local Social Security Administration office, you are automatically enrolled in Medi-Cal and will be sent a Benefits Identification Card (BIC). If you do not qualify for SSI, you may still qualify for Medi-Cal with or without a share of cost (SOC). Contact your Medi-Cal county office for more information.
If you or your spouse anticipates placement in a nursing home, contact your Department of Public Social Services (DPSS) county office to learn about the Medi-Cal rules for long-term care. These rules are very different than the rules that apply if you are not in a nursing home. Learn more about qualifying for Medi-Cal long-term care coverage.
Note: If you are hospitalized and think you may need to go into a nursing home, you may also ask the hospital’s Medi-Cal specialist for assistance.
Apply for Medi-Cal as soon as possible if you think you may not be able to afford your medical expenses or nursing-home placement. Processing your application can take several weeks because Medi-Cal must first determine eligibility by verifying your income and personal assets before coverage can be approved. You may request Medi-Cal to pay retroactively for the three months prior to the month in which you apply.
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