Medi-Cal, the Medicaid program in California, provides health coverage to people with low-income and asset levels who meet certain 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:
- 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
1. What Medi-Cal Covers
Medi-Cal pays for "medically necessary" health care such as:
- Prosthetic and orthopedic devices*
- Hearing aids*
- Medical equipment
- Ambulance services
- Hospice care
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.
You can use Medi-Cal with:
- Original Medicare
- Medicare Advantage (MA) plan
- Medi-Cal managed care plan, if your county has one.
If you choose Original Medicare and fee-for-service 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 doctor and other providers before receiving services, so they can bill Medicare and Medi-Cal directly. Medicare and Medi-Cal will make payments directly to the providers. Many dually eligible beneficiaries choose this option.
If you choose a Medicare Advantage (MA) plan, you have many types of plans to choose from. Yet, the type of plan that works best for people with both Medicare and Medi-Cal is the Special Needs Plan (SNP) for dual eligibles. These plans are also refered to as "D-SNPs".
Note: if you live in 1 of the following 8 counties (Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo or Santa Clara), you may also have the option to receive your care through a new demonstration program called Cal MediConnect. This demonstration is a result of California’s Coordinated Care Initiative, which aims to better integrate care for people with both Medicare and Medi-Cal. People living in 1 of these 8 counties may be able to enroll in a Cal MediConnect managed care plan to receive all their Medicare- and Medi-Cal-covered services. Notices to affected beneficiaries will be sent in January 2014 at the earliest. See CalDuals.org for more information, or call your local HICAP. More information will be posted soon.
Most D-SNPs are made specifically for Medicare beneficiaries who also have full Medi-Cal benefits, and they don't have the cost-sharing (such as copayments, deductibles and coinsurance) and premiums that many of the other types of MA plans do. Learn more about other MA plan types.
If you choose a Medi-Cal managed care plan, or are already in one before becoming eligible for Medicare, you can:
- Stay in your Medi-Cal managed care plan. If so, you may have to enroll in a stand-alone Medicare Part D plan for your prescription drug coverage (See more about Medicare Part D drug coverage);
- Disenroll from your Medi-Cal managed care plan, choose fee-for-service Medicare and Medi-Cal, and enroll in a Medicare Part D plan for prescription drug coverage; or
- Disenroll from the Medi-Cal managed care plan and enroll in a Medicare Advantage D-SNP which includes prescription drug coverage.
Remember, if you choose to a Medi-Cal managed care plan or a Medicare Advantage D-SNP, you must see doctors and other providers in the plan's network. These plans only pay for providers within their network.
*Note: Medi-Cal covers prosthetic and orthopedic devices but not the initial visit, exam, and/or follow-up appointments with a podiatrist, due to cuts made in July 2009. Similarly, Medi-Cal pays for hearing aids but not hearing exams or follow-up hearing aid tests to make sure the devices continue to work properly over time. Coverage for beneficiaries who live in a licensed nursing home, such as a skilled nursing facilitiy, remains the same as it was before July 2009; their Medi-Cal benefits were not affected by the cuts. See the Medi-Cal website for more information.
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. However, Medi-Cal will pay for certain categories of drugs not covered by Part D, including:
- Drugs used for anorexia, weight loss and weight gain
- Drugs used for smoking cessation
- Certain cough and cold drugs
- Certain over-the-counter drugs
- Vitamins and minerals
With Medicare Part D drug coverage, you must make copayments between $1.15 and $6.60 for each prescription in 2013. 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.
To find out if you qualify for one of Medi-Cal’s programs, look at your countable asset levels. You may have up to $2,000 in assets as an individual or $3,000 in assets as a couple. Some of your personal assets are not considered when determining whether you qualify for Medi-Cal coverage. For example, assets that do not count are:
- Your primary home
- One vehicle
- Household goods and personal belongings
- Life-insurance policy with a face value of $1,500 per person
- Prepaid burial plan (unlimited if irrevocable or up to $1,500 if revocable) and burial plot
If you meet the asset requirements, your income determines the Medi-Cal program for which you qualify. See next section.
|(Asset limits are the same for all programs: Single: $2,000; Couple: $3,000)|
|Program / Requirements||Your Monthly Income|
|Supplemental Security Income (SSI)
||Single: up to $866.40/mo.
Couple: up to $1,462.20/mo.
Note: Higher income levels apply for individuals who are blind.
|Aged & Disabled Federal Poverty Level (A&D FPL) Program
||Single: up to $1,188/mo.
Couple: up to $1,603/mo.
|Medi-Cal with a Share of Cost (SOC)
||Single: over $1,188/mo.
Couple: over $1,603/mo.
|250% California Working Disabled (CWD)
||Single: up to $2,394/mo.
Couple: up to $3,232/mo. Note: Income excludes disability benefits
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 $866.40 for an individual or $1,462.20 for a couple (higher income levels apply for individuals who are blind).
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 $2,000 in assets for an individual ($3,000 for a couple). Like SSI, this program does not count all of your assets. For more information, see our Medi-Cal Programs – Qualification at a Glance chart (above).
- Have less than $1,188 in countable monthly income for an individual ($1,603 for a couple).
If your monthly income is higher than the limits to qualify for SSI or the A&D FPL program (see above), but you meet the asset-level requirements, 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: An SOC is paid only for the months you have incurred medical expenses; it is not a monthly premium. 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 $1,300, Medi-Cal subtracts $600 for an SOC of $700. This means you must pay at least $700 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 no longer 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.
The 250% California Working Disabled (CWD) program helps Californians who are working, disabled and have income too high to qualify for free Medi-Cal. Californians who qualify may be able to receive Medi-Cal by paying a small monthly premium based on their income. Premiums range from $20 to $250 per month for an individual or from $30 to $375 for a couple.
To qualify, you must:
- Meet the medical requirements of Social Security's definition of disability, but you are not required to meet the agency's income and work requirements.
- Be working and earning income (this can be part-time work).
- Have assets worth less than $2,000 for an individual or $3,000 for a couple. Note: IRS-approved retirement funds, such as 401(k)s and IRAs, are exempt and not counted.
- Have countable income less than 250% of the federal poverty level (in 2013, this equates to $2,394/mo. for individuals or $3,232/mo. for couples). 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
5. 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.
If you qualify for Medi-Cal and have private health insurance to help cover a high-cost medical condition, Medi-Cal may pay your premiums through its Health Insurance Premium Payment (Medi-Cal/HIPP) program. To qualify, you must:
- Be on Medi-Cal.
- Have private insurance such as employer coverage, individual health insurance or a Medigap policy.
- Have a high-cost medical condition.
- Have a share of cost (SOC) less than $200. Note: Some exceptions exist that allow you to have an SOC over $200.
- Have Medi-Cal determine that it is more cost-effective to pay your premiums than for you to use Medi-Cal.
Note: The Medi-Cal/HIPP program does not help pay the costs of Medicare-covered services, and is not available to members of Medicare Advantage (MA) plans.
For more information, visit Disability Benefits 101. You can also contact HIPP through the California Department of Health Care Services website or at 1-866-298-8443.