Medi-Cal (for People with Medicare)

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:

1. What Medi-Cal Covers
2. Prescription Drugs
3. How to Qualify
4. 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
5. How to Apply
6. Health Insurance Premium Payment (HIPP) Program

1. What Medi-Cal Covers

Medi-Cal pays for "medically necessary" health care such as:

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 either:

• Original Medicare
• Medicare Advantage (MA) plan

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. Most dually eligible beneficiaries choose this option.

If you choose a Medicare Advantage (MA) plan and fee-for-service Medi-Cal, present your BIC to the network providers of the MA plan so they can bill Medi-Cal for any cost-sharing (i.e., deductibles, copayments and coinsurance).

For services covered only by Medi-Cal, such as long-term care in a nursing home, Medi-Cal is the sole payer. Medi-Cal may also pay for certain at-home services through In-Home Supportive Services (IHSS) when you need long-term care.

*Note: Due to Medi-Cal cuts in July 2009, Medi-Cal covers prosthetic and orthopedic devices but not the initial visit, exam, and/or follow-up appointments with a podiatrist. 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.

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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. However, Medi-Cal will pay for certain categories of drugs not covered by Part D, including:

• Benzodiazepines (Xanax, Valium and other drugs often used for anxiety and insomnia)
• Barbiturates (often used for seizure disorders and to relieve anxiety)
• 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 $1.10 and $6.50 for each prescription in 2012. 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 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.

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4. 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 $830 for an individual or $1,407.20 for a couple (higher income levels apply for individuals who are blind).

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:

1. Be aged (65+) or disabled (meet Social Security's definition of disability, even if your disability is blindness).
2. 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).
3. Have less than $1,138 in countable monthly income for an individual ($1,536 for a couple).

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), 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: As of April 1, 2011, 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.

250% California Working Disabled (CWD) Program

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 2011, this equates to $2,269/mo. for individuals or $3,065/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

These rules are explained in more detail in the Medi-Cal section of the Disability Benefits 101 website.

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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.

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6. Health Insurance Premium Payment (HIPP) Program

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.

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