Eligiblity for Medi-Cal through SSI

To qualify for SSI, your monthly income and assets cannot exceed certain limits. In 2007 (April 1, 2007 – March 31, 2008), your monthly income cannot exceed $856 for an individual or $1,502 for a married couple. You can have up to $2,000 in assets as an individual or $3,000 in assets as a couple. These numbers change every year on April 1st.

The income limits for people who are blind are higher:

• For an individual who is blind, monthly income must not exceed $921.
• For a married couple, both of whom are blind, monthly income must not exceed $1,729.
• For a married couple, when one spouse is blind and the other is over age 65 or has a disability, monthly income must not exceed $1,644.

The assets remain the same: $2,000 for an individual, and $3,000 for a couple.

Some of your personal assets — such as your home, personal belongings, and one car used for transportation — are not considered when determining whether you can get Medi-Cal coverage.

If you are not already getting checks, you should contact Social Security at 800-772-1213 about three months before your 65th birthday to sign up for Medicare. They also have a TTY phone connection at 800-325-0778.

Eligiblity for Medi-Cal through the Aged and Disabled Federal Poverty Level program (A&DFPL)

California law allows those whose incomes are above the SSI limits to qualify for full Medi-Cal coverage under a plan called the Aged and Disabled Federal Poverty Level program. These limits also change April 1st of each year.

To qualify, a single person's monthly income must not exceed $1,081 and assets must be at or below $2,000. For married couples, the monthly income limit is $1,502 and the assets limit is at or below $3,000.

These monthly income limits do not include a $20 disregard – an amount of additional income that does not count towards your monthly income limit.

Your home, personal belongings, and one car used for transportation are not counted as assets.

Eligibility for Medi-Cal with a share of cost

If you are not eligible for regular Medi-Cal because of your income level, you may still be eligible for Medi-Cal with a "share of cost." 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" (MNL). Your assets must be at or below $2,000 for an individual and $3,000 for a couple.

In order for Medi-Cal to cover your medical expenses after you meet your share of cost, you must use providers that accept Medi-Cal.

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.

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*, 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 ($93.50 in 2007). 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.

*Note: 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 groups of drugs not covered by Part D. Some of these drugs include:

• 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
• drugs used for smoking cessation

Medi-Cal also pays for some cough and cold drugs, over-the-counter drugs, and vitamins and minerals, and helps pay for the health care items listed above, including your Medicare deductible and coinsurance.

With Medicare Part D drug coverage, you have co-payments between $1 and $5.35 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. See our section Assistance for People with Low Incomes for more information.

Elderly people and/or people with disabilities who qualify for benefits under both Medicare and Medi-Cal are referred to as "dual eligible." Remember that as a dual eligible, you must use providers that accept both your Medicare and Medi-Cal card in order for services to be covered.

Medi-Cal, Medicare & Medigap

If you have Medi-Cal and Medicare, you do not need a Medigap policy. Medi-Cal will pay for more benefits than most Medigap policies, with the exception of coverage when you are out of the country. It is illegal for an insurer to sell you a Medigap policy if you have Medi-Cal. If you have a Medigap policy when you qualify for Medi-Cal, you can keep it if it provides you with access to providers who don't take Medi-Cal, or you can ask the insurance company to suspend your coverage for 24 months. If you later lose your eligibility for Medi-Cal, you can have your policy reinstated or replaced within those 24 months.

When Medi-Cal pays for other health coverage

If you have Medicare and Medi-Cal, you generally do not need to purchase other health insurance.

Medicare Advantage and Medi-Cal

Remember, if you are in a Medicare HMO and you have Medi-Cal, you must use HMO providers for all your Medicare-covered services.

In general, you may only use benefits covered just by Medi-Cal in two situations: 1) when you need services that are not covered by your Medicare HMO, or 2) when you use up all of your HMO's benefits. For example, you can use your Medi-Cal coverage for nursing home care that is not covered by your HMO. Remember that in order for services to be covered, you must use providers that accept Medi-Cal.

Nursing home care

If you or your spouse anticipate placement in a nursing home, contact your county's Department of Social Services to learn about Medi-Cal eligibility rules for long-term care. These rules are very different from the ones that apply if you are not in a nursing home. For more information about eligibility for Medi-Cal long term care, see the website of the California Advocates for Nursing Home Reform at http://www.canhr.org/. Note that Medicare does cover some care in a skilled nursing facility for a limited period of time, as long as the individual needs skilled care on a daily basis. See our section on Medicare Part A for more information.

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).

How to get Medi-Cal

If you think you qualify for Supplemental Security Income (SSI), apply at your local Social Security office. Once your SSI application is approved, you will get Medi-Cal automatically, and a Benefits Identification Card (the Medi-Cal card) will be sent to you. If you do not qualify for SSI, you may still qualify for Medi-Cal with or without a share of cost. Contact your county Department of Social Services.

Apply for Medi-Cal as soon as you know you can't afford your medical expenses or nursing home placement — it takes Medi-Cal time to verify your income and personal assets before Medi-Cal coverage is approved. You may request that Medi-Cal pay retroactively for the three months prior to the month in which you apply.