Medi-Cal (for people with Medicare)
Medi-Cal provides health coverage to people with low income and asset levels who meet certain eligibility requirements. (Medi-Cal is the name for the Medicaid program in California.) While there are several ways to qualify for Medi-Cal, this section focuses only on Medi-Cal beneficiaries who also qualify for Medicare – certain aged and disabled individuals. People who qualify for both Medicare and full Medi-Cal are known as “dual eligibles” or “Medi-Medis.”
On this page:
- What Medi-Cal covers
- Benefits if you have with both Medicare and Medi-Cal
- Prescription drugs
- Medi-Cal with a Share of Cost (SOC)
- How to qualify
- How to apply
- The Health Insurance Premium Payment (HIPP) program
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, adult day health services, home health care, some prescription drugs excluded as a Medicare Part D benefit (discussed in next section), some dental care, prosthetic and orthopedic devices, eyeglasses, hearing aids, medical equipment, ambulance services, and hospice care. In order for Medi-Cal to cover these costs and services, you must 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. Medi-Cal will also cover your Medicare Part A and B deductibles and co-payments and will pay your monthly Medicare Part B premium ($96.40 in 2008). For services that are covered only by Medi-Cal, such as dental care or long-term care in a nursing home, Medi-Cal is the only payer. Medi-Cal may also pay for some at-home services through In-Home Supportive Services (IHSS) when you need long-term care.
2. Benefits if you have both Medicare and Medi-Cal
Medi-Cal can help you pay for "medically necessary" health care, including physician visits, X-ray and laboratory tests, hospital and nursing home care, adult day health services, home health care, certain prescription drugs not covered by Medicare, some dental care, prosthetic and orthopedic devices, eyeglasses, hearing aids, durable medical equipment, ambulance services, and hospice care. Medi-Cal also pays the Medicare deductibles, co-insurance, and monthly Part B premiums ($96.40 in 2008) for people covered by both programs.
Once your Medi-Cal eligibility is established, you will receive a Benefits Identification Card (BIC). To obtain health care services, present both your Medicare card and your BIC to your doctors and other providers.
Make sure your doctor or hospital accepts Medi-Cal as well as Medicare. If you do not get confirmation that your doctor or hospital accepts both Medicare and Medi-Cal before using their services, you may have to pay for some of the services yourself. If your providers accept both Medicare and Medi-Cal, they should bill Medicare and Medi-Cal directly and Medicare and Medi-Cal will make payments directly to the providers.
3. Prescription Drugs
If you are receiving both Medicare and Medi-Cal benefits, the Medicare Part D drug benefit now provides your prescription drug coverage instead of Medi-Cal. Medi-Cal, however, still pays for some categories of drugs not covered by Part D, including: benzodiazepines (such as Xanax and Valium, and other drugs often used for anxiety and insomnia); barbiturates (often used for seizure disorders or to relieve anxiety); drugs used for anorexia, weight loss, or weight gain; and drugs used for smoking cessation. Medi-Cal also pays for some cough and cold drugs, over-the-counter drugs, and vitamins and minerals.
With Medicare Part D drug coverage, you have co-payments between $1.05 and $5.60 for each prescription. A program called the Low-Income Subsidy (or “Extra Help”) will pay for part or all Medicare Part D drug benefit plan premiums, depending on the plan you are enrolled in. For more information on this Extra Help, see our section on Extra help with Part D prescription drug costs. For information on the Medicare Part D drug benefit, see our section on Prescription Drugs.
4. Medi-Cal with a Share of Cost (SOC)
If your monthly income is higher than the income limits (explained below in the How to Qualify section), but you still meet the asset levels, you may still be eligible for Medi-Cal with a share of cost (SOC). The SOC functions like a deductible. You must pay this amount in any month that you incur medical costs. Medi-Cal will pay the remaining amount of your medical bills for that month.
Note: A 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. The remainder is your SOC. This SOC is the amount you must pay before Medi-Cal will pay the rest of that month’s medical bills.
5. How to Qualify
To see if you qualify for Medi-Cal, you must look at both your countable income and asset levels. You can 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 or not you qualify for Medi-Cal coverage. For example, assets that do not count are: your primary home, one vehicle, household goods and personal belongings, a life insurance policy with a face value of $1500 per person, a pre-paid burial plan (unlimited if irrevocable and up to $1500 if revocable) and a burial plot.
If you qualify for Supplemental Security Income (SSI), then you automatically qualify for full Medi-Cal coverage. To qualify for SSI, applicants must be 65-years-old or over, blind, or disabled. Your monthly countable income cannot exceed $870 for an individual or $1,558 for a married couple (higher income levels apply for individuals who are blind).
California state law also allows individuals with incomes above the SSI limit to qualify for full Medi-Cal coverage without a Share of Cost (SOC) – (see below for an explanation of Share of Cost). This program is called the Aged and Disabled Federal Poverty Level Program (A&D-FPL). If your countable income does not exceed $1,097 per month, you can qualify for full Medi-Cal benefits. However, your assets must still be under $2,000. The limit for married couples to receive Medi-Cal with no SOC is $1,558 per month and their assets must still be under $3,000.
6. How to Apply
When you apply for SSI (through your local Social Security Administration office) and qualify, you are automatically enrolled in Medi-Cal and 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. To find out more information about your eligibility, contact your county Department of Social Services (DSS) office. See a list of offices by county.
If you or your spouse anticipate placement in a nursing home, contact your local county Department of Public Social Services (DPSS) office to learn about the Medi-Cal rules for long-term care. These rules are very different than the Medi-Cal rules that apply if you are not in a nursing home. For more information about qualifying for Medi-Cal long-term care coverage, see the California Advocates for Nursing Home Reform website.
Note: If you are hospitalized and think you might have to go to a nursing home, you can also ask to speak with the hospital’s Medi-Cal specialist for assistance.
Apply for Medi-Cal as soon as you know you can’t afford your medical expenses or nursing home placement because processing your application takes time. Medi-Cal must first determine your eligibility by verifying your income and personal assets before any Medi-Cal coverage can be approved. You can request that Medi-Cal pay retroactively for the three months prior to the month in which you apply.
7. The Health Insurance Premium Payment (HIPP) program
The Health Insurance Premium Payment (HIPP) may pay premiums for private health coverage (including Medigap policies, though this is rare) for people who are on Medi-Cal.
The HIPP program may pay the premiums when an individual has a high-cost medical condition that is covered by an employer group health plan, individual health insurance, or a Medigap policy and it is determined to be more cost-effective to pay the premiums than for the individual to use Medi-Cal. For more information, contact HIPP through the California Department of Health Services (866-298-8443) or visit Third Party Liability and Recovery.
Page updated July 10, 2008