DB101 California - Medi-Cal: Frequently Asked Questions (2024)

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You can qualify for Medi-Cal by meeting the requirements of a Medi-Cal eligibility category, which are also called programs. There are many Medi-Cal programs, and each has unique rules. DB101 gives detailed explanations of the following Medi-Cal programs:

• Income-Based

• SSI-Linked

• Aged & Disabled Federal Poverty Level

• Working Disabled

• Aged, Blind, & Disabled - Medically Needy

To learn about other eligibility categories, speak with a benefits planner or a Medi-Cal eligibility worker at your local county social services agency.

Medi-Cal provides coverage for doctor visits, hospital stays, prescription drugs, rehabilitation, and other medical services. Some Medi-Cal programs provide access to all of these services (full-scope Medi-Cal), while others only provide some of them (partial-scope Medi-Cal). For a more detailed list of Medi-Cal services, see the glossary definition of full-scope Medi-Cal.

If you get Medi-Cal and have certain health conditions, you may also have access to other Medi-Cal benefits, including:

• Medi-Cal's Health Insurance Premium Payment (Medi-Cal/HIPP) program
• In-Home Supportive Services (IHSS), and
• Medicare Savings Programs.

See Other Medi-Cal Programs for more details.

There are different ways to apply for Medi-Cal:

• Online using BenefitsCal. BenefitsCal lets you apply for other programs like CalFresh or CalWORKs at the same time.
• Online using Covered California, an online one-stop shop where you can learn about your public and private coverage options.
• In person at your local county social services agency.
• Using a paper application (available in 11 languages) and mailing it in to your local county social services agency.

Note: If you get Supplemental Security Income (SSI) or used to and now are on SSI 1619(b), you automatically get Medi-Cal coverage. You do not need to apply for Medi-Cal.

There are a number of ways to protect your Medi-Cal coverage. You may first want to consider switching eligibility categories. For example, if you lose your Medi-Cal because your income from a new job is too high, you may want to consider the Working Disabled Program.

If you're on SSI, there are two programs that can help you keep your Medi-Cal when your countable income goes above the limit. If it's too high because you return to work, the 1619(b) provisions protect your Medi-Cal. If it goes above the limit because of an SSDI or CDB cost of living increase and you lose your SSI, the Pickle Amendment allows you to keep your Medi-Cal.

Yes. Your enrollment in private health coverage will not jeopardize your participation in Medi-Cal. Obtaining private health coverage may allow you to access providers or services you may not have had available to you on Medi-Cal alone. If you have private health coverage and are eligible for Medi-Cal, you may qualify for the Medi-Cal/HIPP program, which can pay for your insurance premiums.

When using private health coverage and Medi-Cal simultaneously, the private health coverage is billed first. After the private health carrier pays or denies a claim, Medi-Cal is then billed and will pay for services it covers.

Note: You cannot get government subsidies to buy an individual health plan on Covered California if you are on Medi-Cal.

Yes. Medi-Cal is designed to help you work. If you start earning money and your income goes up, there are programs and rules that will help you stay covered:

• If you have a disability and work, you can switch to Medi-Cal's Working Disabled Program. You’ll have to begin paying for your Medi-Cal coverage, but the amount is small compared to the income you’re earning.
• 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.
• If you're on SSI-Linked Medi-Cal and your SSDI or CDB benefits increase and make you ineligible for SSI, you can keep your Medi-Cal thanks to a rule called the Pickle Amendment.
• If your income goes up so much that none of these rules help you keep your Medi-Cal and you cannot get coverage from an employer, you may qualify to get government help paying for a private health coverage plan on Covered California. See DB101's Buying Health Coverage on Covered California article for more information.

Aged and Disabled Federal Poverty Level Medi-Cal provides free, full scope Medi-Cal services for disabled or aged individuals who meet the income requirements of the program. Blind people are also eligible, but must be determined disabled.

To qualify for the Aged and Disabled Federal Poverty Level Medi-Cal, an individual's monthly total countable income (minus a Maintenance Needs Allowance and any health, vision, and dental insurance premiums) must be less than $1,677 ($2,268 for a couple).

No, Medi-Cal does not have a resource limit.

Medically Needy Medi-Cal provides full scope Medi-Cal services to aged, blind, or disabled people with income above the eligibility levels of no-cost Medi-Cal programs. The program usually requires that you incur a monthly share of cost, similar in principle to a monthly copayment.

This Medi-Cal eligibility category is often called “share of cost” Medi-Cal. A share of cost is usually more expensive than Medi-Cal's Working Disabled Program, if you work.

First, use the countable income calculation to find your countable income.

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

Finally, subtract a maintenance needs level (MNL) for your family size: If you are the only person in your family, deduct $600; if there are two in the family, deduct $750; if there are 2 adults or 1 adult and 2 children= $934, 4 people= $1,100; 5= $1,259; 6= $1,417; 7= $1,550; 8 = $1,692.

The figure you get after this calculation is the amount you must pay at the beginning of each month before Medi-Cal begins paying for services. The $600 figure is Medi-Cal’s maintenance need level.

The WDP program provides full scope Medi-Cal to disabled individuals who work and have income that is too high to qualify for other Medi-Cal categories. For this program, you can have up to 250% of the Federal Poverty Level in countable income and still receive Medi-Cal benefits. Note: Medi-Cal's Working Disabled Program used to have a monthly premium. Starting on July 1, 2022, there is no more premium. Learn more about this change.

You may be eligible for Medi-Cal's Working Disabled Program (WDP) if you meet all the following criteria:

1. You meet Medi-Cal’s definition of disability. Your earnings due to work are not considered when determining whether a disability exists or persists.
2. Your total countable income can not exceed 250% of the Federal Poverty Level (see FAQ 3);
3. Your countable unearned income is less than the appropriate SSI/SSP benefit rate. Again, disability income doesn't count.
4. You are working.

No. This program uses Social Security's countable income calculation to determine your income. Additionally, the WDP Program does not count unearned income from private or public disability benefits (such as SDI, SSI, SSDI, STD, LTD ) when determining your countable income.

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

Medi-Cal's Working Disabled Program costs the same as regular full-scope Medi-Cal without a share of cost: there is no monthly premium, but there may be small copayments for some services or medications. Note: Medi-Cal's Working Disabled Program used to have a monthly premium. Starting on July 1, 2022, there is no more premium. Learn more about this change.

Use the Medi-Cal for the Working Disabled Estimator to get an idea of whether you'd qualify for this program.

No, Medi-Cal's Working Disabled Program does not have a resource limit.

Work is not specifically defined by Medi-Cal's Working Disabled Program (WDP). A disabled worker on the WDP Program must provide proof of current employment. Proof of employment includes pay stubs or written verification of employment from your employer.

If you are self-employed, you will have to provide records such as recent IRS tax returns to demonstrate employment. Also, for the independent contractor, verification may be provided with a 1099 IRS form as proof of employment.

Also, you are still considered to be working under the WDP Medi-Cal if you are receiving vacation or sick leave pay from your employer.

To apply for Working Disabled Program (WDP), request an appointment with your local county WDP coordinator. The Department of Health Care Services has a webpage listing where to find a county social services agency.

Medi-Cal provides applications in eleven languages. You can download an application online, but you must submit your application in person or by U.S. mail.

If you are currently enrolled in another eligibility category of Medi-Cal, talk to your Medi-Cal eligibility worker and ask to be transferred to this program.

Although both programs provide full scope Medi-Cal, there are several differences between SSI 1619 (b) provisions and WDP Medi-Cal. SSI 1619(b) provisions allow you to keep Medi-Cal at no cost, but limits your income to the state's threshold amount and has special rules for retirement funds, which sometimes are exceptions and require approval from Social Security. WDP Medi-Cal, on the other hand, does not have any limitations on retirement funds. In order to qualify for SSI, Social Security has determined that you are unable to work for at least twelve months. WDP does not have this rule and thus allows you to work with a disability.

As your circ*mstances change, it is important to review which Medi-Cal eligibility category may be most cost effective for you.

HIPP stands for Health Insurance Premium Payment. The Medi-Cal/HIPP program pays private health insurance premiums so that individuals with high cost medical conditions may continue their private health coverage rather than relying solely on Medi-Cal.

To be eligible for the Medi-Cal/HIPP program you must:

• have a high-cost medical condition such as HIV/AIDS, cancer, pregnancy and organ transplantation; and
• be insured under a private health insurance policy that does not exclude the individual’s high-cost medical condition. The policy can be individual, group, continuation coverage such as COBRA, Cal-COBRA or OBRA (for self-insured trusts) or COBRA conversion policy.

Those ineligible for the HIPP program include individuals enrolled in:

• Medi-Cal Managed Care program
• Medi-Cal prepaid health plan
• County Organized Health System (COHS)
• Medicare
• TRI-CARE (formerly known as CHAMPUS)
• County Health Initiative
• Geographic Managed Care Program of the County Medical Services Program (CMSP), and
• California’s Major Risk Medical Insurance Pool (MRMIP).

To apply for the HIPP program you must submit the following:

• Medi-Cal/HIPP Department of Health Care Service Form 6172 (HIPP application);
• An insurance policy or description of benefits from the insurer or employer;
• A physician letter of diagnosis of high-cost medical condition; and
• A premium payment notice or election form from COBRA or Cal-COBRA.