Medi-Cal and Medicare for people with disabilities

Medi-Cal, known in other states as Medicaid, is the federal- and state-funded health insurance program for people with low incomes in California. If you are blind or you have a disability and you receive Supplemental Security Income (SSI), you are automatically eligible for Medi-Cal. To qualify for SSI, your monthly income and assets cannot exceed certain limits. To learn about the income and asset limits, as well as the eligibility criteria and other aspects of the program, see our Medi-Cal section.

In California, about 1 million people receive both Medicare and Medi-Cal benefits. Both programs help pay for medical care. Medi-Cal can help supplement Medicare services and can often help pay for Medicare premiums, deductibles, and co-payments. In some cases, Medi-Cal may be used to pay for private health coverage premiums. Medicare Part D has special rules and provides financial help for people on Medicare and Medi-Cal. (See our section Extra help with Part D costs for people with low incomes.)

People with disabilities and/or the elderly who qualify for benefits under both Medicare and Medi-Cal are referred to as "dual eligible" or “Medi-Medi.”

Note: Many people with disabilities who qualify for SSI, including most children, are not eligible for Medicare benefits because they do not have the work credits to qualify for Social Security Disability Income (SSDI) benefits. These people are covered by Medi-Cal only, not by Medicare.

If you have both Medicare and Medi-Cal, make sure the medical providers you choose will accept both sources of payment for your care. Otherwise, you may face billing delays or you may have to pay unexpected medical costs if a provider accepts Medicare, but does not also accept Medi-Cal payment.

In general, it is often easier for people with disabilities to find medical providers who will accept them as patients when they have both Medicare and Medi-Cal coverage than it is if they have just Medi-Cal alone.

Payment of health care services

For medical benefits that are covered by Medicare and Medi-Cal, Medicare is the primary payer and Medi-Cal is the secondary payer.

For services that are only covered by Medi-Cal, such as dental care or long term care, Medi-Cal is the sole payer.

Other ways to qualify for Medi-Cal

There are many ways to qualify for Medi-Cal besides SSI eligibility. Outlined below are some of the most common ways California’s Medicare beneficiaries qualify. Also mentioned is a program that in certain situations helps Medi-Cal-eligible people who have a high cost medical condition pay the premiums of a private health insurance policy.

Medi-Cal’s 250% California Working Disabled Program (CWD)

If you are working or planning to work, disabled, have Medicare, and your income is too high to qualify for free Medi-Cal, you may be eligible for Medi-Cal’s little known 250% California Working Disabled program. With CWD, you can get Med-Cal by paying a small monthly premium. Premiums range from a minimum of $20 to a maximum of $250 per month for an individual or from $30 to $375 for a couple.

To qualify for the Medi-Cal’s 250% California Working Disabled program, you must:

Meet the medical requirements of Social Security’s definition of disability, but you don’t have to meet Social Security’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 and $3,000 for a couple. Note: Any IRS approved retirement fund, like a 401(k) or an IRA, is exempt and not counted for this Medi-Cal program.
Have countable income less than 250% of the federal poverty level. ($2,167/month for individuals and $2,917/month for couples in 2008). Any disability income does not count for the 250% CWD program. This means that Social Security Disability Insurance (SSDI), Worker’s Compensation, California State Disability Insurance, and any federal, state, or private disability benefits are not considered as income for this program.

These rules are explained in more detail at the Disability Benefits 101 website – See the Medi-Cal section on that site.

Medi-Cal’s Aged & Disabled Federal Poverty Level program

If you are aged 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. You must:

Be either aged (65+), or disabled (meet Social Security’s definition of disability, even if your disability is blindness).
Have less than $2,000 in assets ($3,000 for a couple). Like SSI, this program does not count all of your assets.
Through March 31 of 2009, have less than $1,097 in countable monthly income for an individual ($1,558 for a couple). This Medi-Cal program uses SSI countable income rules with a few extra rules you need to know (See the Disability Benefits 101 website - Medi-Cal section).

Medi-Cal with a Share of Cost (also known as Medi-Cal’s Aged, Blind, and Disabled Medically Needy program)

If you do not qualify for Medi-Cal because you get SSI, the Medi-Cal A&D FPL program or the Medi-Cal’s 250% California Working Disabled program, you may still be able to get Medi-Cal with a Share of Cost (SOC). A share of cost functions like a deductible. You must pay or promise to pay your share of cost in any month you incur medical costs. Then Medi-Cal will pay the balance of your medical bills. (A share of cost is not a monthly premium; it is met only in the months you have medical costs.)

Your share of cost is determined by your monthly income. Medi-Cal allows you to keep a certain amount of your income for living expenses. If medical bills leave you with less than $600 per month for living expenses as a single person or $934 per month as a married couple, then you qualify for this program. These figures are known as the "maintenance needs level". Your assets must be at or below $2,000 for an individual and $3,000 for a couple.

With share of cost Medi-Cal, Medi-Cal will still pay for your Part B premiums — even in the months you do not incur medical expenses.

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

If you qualify for Medi-Cal and have private health insurance to help cover a high-cost medical condition, in certain situations Medi-Cal may help you keep your private insurance by paying for your health insurance premiums. To qualify you must:

be on Medi-Cal,
have private health insurance (such as employer coverage, individual health insurance or a Medigap policy – this is rare),
have a high cost medical condition,
NOT have a Share of Cost greater than $200, and
have Medi-Cal determine it to be more cost-effective to pay your premiums than for you to use Medi-Cal.

Note that the Medi-Cal/HIPP program does not help pay for the costs of any Medicare services, and is not available to those enrolled in a Medicare Advantage plan.

For more information, visit Disability Benefits 101. You can also contact HIPP through the California Department of Health Care Services website or at 866-298-8443.

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Page updated April 29, 2008