Medi-Cal
The Basics
Medi-Cal is a program that pays medical expenses for people with
low income. This includes people who are aged, disabled, or have
high medical costs. If you meet the requirements of the program,
Medi-Cal will help pay for doctor visits, hospital stays,
prescription drugs, rehabilitation, and other medical services.
Medi-Cal is California’s part of a national health coverage
program called Medicaid. Each state runs its own Medicaid
program. The states have to follow certain national Medicaid
rules, but they have flexibility in how they run their programs.
The state Medicaid programs are paid for with a combination of
county, state, and federal money.
You can think of Medi-Cal as a single program that you can
qualify for in many different ways. The different ways to get
Medi-Cal are called eligibility categories. There are over 90
eligibility categories, each with its own rules and requirements.
This site will explain the Medi-Cal benefit in more detail and
describe four common eligibility categories. It will also explain
how you can keep your Medi-Cal coverage if you lose it because
of a change in income, and how Medi-Cal may help pay for the
premiums of other insurance programs.
The Details
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Medi-Cal Services
Getting Medi-Cal – Eligibility Categories and Application
Medi-Cal Eligibility Categories
o SSI-Linked Medi-Cal
o Aged & Disabled Federal Poverty Level Medi-Cal
o California’s 250% Working Disabled Program
o Aged, Blind, & Disabled Medically Needy Medi-Cal
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Keeping Your Medi-Cal
o 250% California Working Disabled Program
o SSI’s 1619(b) Provisions
o Pickle Amendment
Other Medi-Cal services
o Medicare Savings Programs
Medi-Cal’s Health Insurance Premium Payment (MediCal/HIPP)
Other Information
Sources
Medi-Cal Services
Medi-Cal pays for a wide variety of medical expenses:
Primary Medical
Care
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Doctor visits
Diagnostic
testing
Emergency
services
Surgery
Hospitalization
Prescription
drugs
Dental services
Health
screenings for
kids
Medi-Cal Services
Ongoing Care &
Other medical
Recovery
related costs
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Personal care
services (IHSS)
Occupational &
physical therapy
Outpatient drug
abuse services
Nursing facility
stays
Adult day health
care
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Medical supplies
Durable medical
equipment
Transportation
to doctor visits
Transportation
costs for children
with disabilities
Depending on how you qualify for Medi-Cal, the program may pay
for all of these services (full-scope Medi-Cal) or just some of
them (partial-scope Medi-Cal).
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Like other health coverage plans, Medi-Cal has rules about what
it will cover. For example, Medi-Cal only pays for prescriptions
that are on its list of accepted drugs. Along the same lines, it may
refuse to pay for certain procedures like cosmetic surgery, and it
will require that you get prior authorization for some services. If
Medi-Cal decides not to pay for something and you think it
should, you can appeal the decision.
If you have Medi-Cal and another health insurance policy, MediCal will generally require that the other policy be billed first. This
is why Medi-Cal is known as the “payer of last resort”.
Getting Medi-Cal – Eligibility Categories and Application
You can think of Medi-Cal as a single program that you can
qualify for in many different ways. These different ways are called
eligibility categories. For example, SSI-Linked Medi-Cal is an
eligibility category that allows people who qualify for SSI to
automatically get Medi-Cal. There are over 90 eligibility
categories, each with its own rules and requirements. Once you
meet the requirements of an eligibility category, you are eligible
for either full or partial-scope Medi-Cal.
Db101 describes the four eligibility categories that people with
disabilities most often use:
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If you qualify for SSI (Supplemental Security Income), you
are automatically eligible for SSI-Linked Medi-Cal
If you are aged or disabled, you may be eligible for Aged &
Disabled Federal Poverty Level Medi-Cal
If you are disabled and working, you may be eligible for
California’s 250% Working Disabled Program. You will
have to pay a small premium for Medi-Cal coverage, but you
can have countable income up to 250% of the Federal
Poverty Level
If you are aged, blind, or disabled, but your income is too
high for other Medi-Cal programs, you may be eligible for
Aged, Blind, and Disabled – Medically Needy Medi-Cal.
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For this program, you may need to spend a certain amount
of your own money before Medi-Cal begins to pay for
medical services. This payment is called a share of cost.
You don’t need to do anything extra to get SSI-Linked Medi-Cal.
Just apply for SSI by calling (1-800-772-1213 voice, 1-800-3250778 TTY) or visiting your local Social Security office . You can
apply for the other categories at your local county welfare office
. Also, there are Medi-Cal eligibility workers at many hospitals
and clinics who can process applications.
Medi-Cal Eligibility Categories
SSI-Linked Medi-Cal
One way to get Medi-Cal is by qualifying for an SSI benefit. SSI is
a federal program for people with low income who are aged,
blind, or disabled. To receive a benefit, you must:
1. Meet Social Security’s definition of disability, blindness, or
age (65+).
2. Not be doing Substantial Gainful Activity. This means that
your gross earnings are less than a certain amount of money
each month. For 2006, the limit is $860 ($1,450 for the
blind).
3. Have less than $2,000 in assets ($3,000 for a couple). SSA
does not count all of your assets. Click here for a list of
exemptions.
4. Have Total Countable Income that is less than the SSI/SSP
maximum benefit amount. For 2006, that monthly amount
is$836 for a disabled individual living independently ($1,472
for a couple in the same situation). Maximum benefit
amounts vary based upon your living situation and disability.
Click here for a chart detailing all of the payment
standards.
For this final requirement, SSI uses a calculation to figure out
how much of your income to count.
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Step 1: If you have monthly unearned income (for example, an
SSDI benefit, a pension, dividends), subtract a $20 "General
Income Exclusion" from it to calculate your countable unearned
income. If you do not have unearned income, this exclusion is
applied to any earned income.
Countable Unearned Income Calculation
Monthly Unearned Income
-
$20 General Income Exclusion
= Countable Unearned Income
Step 2: If you have monthly earned income (for example,
wages), subtract a $65 dollar "Earned Income Exclusion" from it
(along with the remainder of the $20 "General Income Exclusion"
that you have not applied to Unearned Income), along with any
Impairment Related Work Expenses, and divide the resulting
figure by two to find your countable earned income. If you have
Blind Work Expenses, subtract them after you divide.
Countable Earned Income Calculation
Monthly Earned Income
-
$65 Earned Income Exclusion
$20 General Income Exclusion
- (only if you haven't already applied it to unearned
income)
-
Impairment Related Work Expenses
÷2
-
Any Blind Work Expenses
= Countable Earned Income
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Step 3: Add your countable unearned income to your
countable earned income to find your total countable
income.
Total Countable Income Calculation
Countable Unearned Income
+ Countable Earned Income
= Total Countable Income
*If you are married, SSA may add your spouse’s income and
assets to yours. This is a process called deeming.
SSA will review your application to see if you meet the income,
asset, and disability requirements. If you do, you will receive an
SSI benefit check. When you qualify for SSI, you automatically
get Medi-Cal. SSA reports your Medi-Cal eligibility to the local
county welfare office, so you do not need to apply for Medi-Cal
separately. Your Medi-Cal coverage begins the same month that
your SSI benefit begins. If you qualify for Medi-Cal through
your SSI eligibility, you will receive free, full-scope MediCal coverage. For more information on the SSI program, see
db101’s SSI program description.
Aged & Disabled Federal Poverty Level Medi-Cal
If you are aged or disabled, and are not eligible for SSI, you may
be able to get Medi-Cal through the Aged & Disabled Federal
Poverty Level (A &D FPL) program. You must:
1. Be either 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 ($3,000 for a couple). Like
SSI, this program does not count all of your assets. Click
here for a list of exemptions.
3. Have less than $1,047 in countable income for an individual
($1,472 if you are a couple).
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The rules for counting income are similar to those used for the
SSI program, with a few additional deductions:
First, find your total countable income using Social Security’s
rules (see above).
Next, take the number of people in your household who are not
applying for the A& D FPL program, and use it to figure out your
Maintenance Needs Allowance. Subtract this amount from your
total countable income:
Maintenance Needs Allowance
Number of People in Your
MNA (Amount to subtract
Household who are not
from your countable income)
applying for the A & D FPL
program
1
$600
2
$750
3
$934
4
$1100
5
$1259
6
$1417
7
$1550
8
$1692
*adapted from HCA
Then, subtract any health insurance premiums that you pay.
These include Medicare, health, vision, and dental insurance
premiums.
Finally, if you are living in a board and care facility, subtract
$315.
The number you get is the amount of income that is counted for
the A & D FPL program. For 2006, if it is less than $1,047 for
individuals or $1,472 for a couple, then you are eligible for
free, full scope Medi-Cal.
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California’s 250% Working Disabled Program
If you are working, disabled, and your income is too high to
qualify for free Medi-Cal, the California 250% Working Disabled
(250% CWD) Program may allow you to get Medi-Cal by paying a
small monthly premium. To qualify, you must
1. Meet Social Security’s medical definition of disability only.
2. Be working and earning income. The Medi-Cal regulations do
not define what “working” means for this program, and you
can qualify if you are working part time. You can use paystubs or other written verification from an employer to prove
that you’re working
3. Have assets worth less than $2,000 for an individual
($3,000 for a couple). The same asset exclusions apply for
this program as the ones mentioned above. Additionally,
retirement funds like 401(k)’s are not counted as assets for
this program.
4. Have countable income less than 250% of the Federal
Poverty Level. There is one major difference in the income
calculations from those described above. Disability income
does not count for the 250% CWD program. This means
that SSDI, Worker’s Compensation, California State
Disability Insurance, and any federal, state, or private
disability benefits are not considered as income for this
program.
For 2006, the monthly countable income limits for this program
are $2,042 for individuals and $2,750 for couples. These figures
are calculated by taking the yearly FPL ($9,800 for individuals,
$13,200 for couples), dividing them by 12, multiplying that figure
by 2.5, and then rounding up to the nearest dollar.
Keep in mind that these are countable income limits, which is
your gross income minus certain deductions. Your gross income
can be much higher than your countable income. For example, an
individual with no unearned income or IRWEs can make $50,028
a year in gross income and still be eligible for this program.
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The premium you pay depends on your countable income:
2006 Premium Table using Monthly Net Countable Income
Countable
Countable
Premium for Premium for
Earned
Earned
Eligible
Eligible
Income From: Income To:
Individual
Couple
$1
$600
$20
$30
$601
$700
$25
$40
$701
$900
$50
$75
$901
$1,100
$75
$100
$1,101
$1,300
$100
$150
$1,301
$1,500
$125
$200
$1,501
$1,700
$150
$225
$1,701
$1,900
$175
$275
$1,901
$2,042
$200
$300
$2,043
$2,100
N/A
$300
$2,101
$2,750
N/A
$375
* Adapted from HCA
The Medi-Cal Third Party Liability Branch will bill you for this
premium on the 23rd of each month. Once you pay the monthly
premium, you will receive full-scope Medi-Cal.
Aged, Blind, & Disabled Medically Needy Medi-Cal
If you cannot qualify for free Medi-Cal or the 250% CWD
program, you may be able to get Medi-Cal through the Aged,
Blind, & Disabled - Medically Needy (ABD – MN) program, but you
may have to pay a share of cost. A share of cost is a certain
amount of money you must spend on medical care each month
before Medi-Cal begins to pay for services. To qualify for the
program, you must:
1. Meet Social Security’s requirements for age, blindness, or
disability.
Page 9 of 20
2. Meet the Medically Needy program’s property requirements.
These requirements depend on your family size:
Property Limits, Medically Needy Program
Family Size
Property Limit
1
$2,000
2
$3,000
3
$3,150
4
$3,300
Per Add'l Person
Add $150
*From HCA
To find out how much your share of cost will be:
First, find your total countable income using SSA rules (see
above)
Next, Subtract the Maintenance Needs Level for your family size.
(For this program, you include yourself in the family. So, if you
have a spouse and 2 children, your family size is 4.)
Finally, subtract any health, vision, and dental insurance premium
payments
Family Maintenance Need Level (MNL)
(unchanged since July 1, 1989)
Family Size
MNL
1
$600
2
$750
2 adults
$934
3
$934
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Family Maintenance Need Level (MNL)
(unchanged since July 1, 1989)
Family Size
MNL
4
$1,100
5
$1,259
6
$1,417
7
$1,550
8
$1,692
9
$1,825
10
$1959
* From HCA
The resulting figure is your share of cost for that month. If you
get a number that is 0 or less, then you have no share of cost for
that month. For example, if you’re living alone and have $800 in
countable income, your share of cost for that month is $800 $600 = $200. You will only have a share of cost in the months
when you have medical services.
HCA publishes fact sheets that are county specific and translated
into a variety of languages on ways to spend your share of cost
.
Eligibility Categories Summary
Must
Meet
SSA's
definition
of:
Income
Limits:
SSI Age,
Gross
Linked blindness, Income
or
Less than
How
Countable Cost of Benefit
Income is
Assets
Benefit
Counted
Limits
SSA's
countable
income
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Up to
Free
$2,000 for
Individual,
Fullscope
Medi-
Eligibility Categories Summary
Must
Meet
SSA's
definition
of:
disability
Income
Limits:
How
Countable Cost of Benefit
Income is
Assets
Benefit
Counted
Limits
SGA
calculation $3,000 for
($860),
couples
Countable
income
less than
the
SSI/SSP
benefit
amount for
your living
situation
Cal
A & D Age or
FPL disability
Countable
Income
less than
$1,047 for
an
individual,
$1,472 for
a couple
SSA's
countable
income
calculation
- MNA for
number of
household
members
not
applying –
health,
vision, and
dental
insurance
premiums
Up to
Free
$2,000 for
Individual,
$3,000 for
couples
Fullscope
MediCal
250% Disability
CWD
Countable
Income
less than
SSA's
countable
income
Up to
Sliding
Full$2,000 for scale
scope
Individual, premium Medi-
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Eligibility Categories Summary
Must
Meet
SSA's
definition
of:
ABD
MN
Age,
blindness,
or
disability
Income
Limits:
How
Countable Cost of Benefit
Income is
Assets
Benefit
Counted
Limits
250% of
the Federal
Poverty
Level
($2,042
per month
for
individuals,
$2750 for
couples)
calculation,
but any
disability
income is
not
considered
income
$3,000 for
couples.
Money in
retirement
accounts is
not
considered
as an
asset
No income
limit, but
your
countable
income
determines
your share
of cost
SSA's
countable
income
calculation
- MNA for
number of
people in
household,
including
the
applicant –
health,
vision, and
dental
insurance
premiums
Up to
Share of Full$2,000 for cost
scope
individuals,
Medi$3,000 for
Cal
couples,
with an
additional
$150 per
additional
family
member
* all figures are given for 2006
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Cal
It’s important to remember that these are just 4 of the many
ways to get Medi-Cal. To learn about other eligibility categories,
you can visit a benefits planner or talk to a Medi-Cal eligibility
worker.
Keeping Your Medi-Cal
Medi-Cal eligibility categories have complicated rules for how
much money you can earn. So, when your income changes, it
may affect your eligibility for Medi-Cal coverage. There are,
however, a number of programs designed to help you keep your
coverage when your income goes up.
250% California Working Disabled Program
If you’re receiving free Medi-Cal and your income goes up
because you are working, you may be eligible to switch to the
250% CWD program. Medi-Cal workers are required to
automatically check to see if you are eligible for this program
when your income disqualifies you from your eligibility category.
If they don’t, you should ask them to. You’ll have to begin paying
for your Medi-Cal coverage, but the amount is small compared to
the income you’re earning. See above for a description of this
program.
SSI’s 1619(b) Provisions
If you’re on SSI-Linked Medi-Cal, and then your SSI benefit goes
to zero because you go back to work, a section of the SSI
regulations called the 1619(b) provisions allow you to keep your
Medi-Cal coverage. In order to continue your Medi-Cal coverage
under this program, you must:
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Have been eligible for an SSI cash payment for at least 1
month
Still meet SSI requirements, like disability, blindness, or
age, that don’t have to do with income
Need Medi-Cal coverage to continue working, and
Page 14 of 20

Have less than $32,499 in gross earnings or have high
medical expenses that will be evaluated on a case by case
basis. Note that this program does not use the countable
income calculation.
The $32,499 income limit is called a threshold amount. This is
what Social Security calculates as the value of your SSI and MediCal benefits. They determine this based on the SSI benefit in
California, along with averages of medical costs in the state. So,
if you’re earning enough money to replace the benefits and cover
your medical costs without help from the government, then
you’re usually not eligible for the program.
If your expenses are higher than the state average, Social
Security may increase the threshold on case-by-case basis. If you
have IRWEs , BWEs , are contributing to a PASS , have a
publicly funded personal assistant, or have medical expenses
higher than the state average, you may be eligible for an
individual threshold amount.
Pickle Amendment
When calculating your countable income, SSI considers any
SSDI benefits as unearned income. SSDI benefits increase
every year to cover cost of living increases. This increase may be
enough to make you ineligible for SSI, and the Medi-Cal linked to
it. The Pickle Amendment protects Medi-Cal coverage for people
in this situation. In other words, if you lose your SSI benefit
because of a cost of living increase in your SSDI benefit, you can
keep your Medi-Cal.
For more information, see Health Consumer Alliance’s excellent
pamphlet on the Pickle Amendment .
Other Medi-Cal services
Besides health care services, Medi-Cal also pays for health
insurance premiums in certain circumstances. There are a
Page 15 of 20
number of premium payment programs, organized into the
following 2 categories:
Medicare Savings Programs
There are four programs that have Medi-Cal pay for Medicare
premiums, co-payments, or deductibles. These programs are
known as Medicare Savings Programs or Medicare Buy-Ins.
Each program has specific income limits and pays for different
Medicare costs:
The Qualified Medicare Beneficiary (QMB) program pays for
Medicare Part A and Part B premiums, coinsurance and
deductibles. To qualify, an individual must:
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Be eligible for Medicare Part A and Part B
Have countable income at or below 100% of the
Federal Poverty Level ($817 per month for 2006,
$1,100 for couples)
Have assets at or below the limit ($4,000 for
individuals, $6,000 for couples)
Meet Medi-Cal requirements besides income and assets
limits
This program does not apply benefits retroactively.
The Specified Low-Income Medicare Beneficiary (SLMB)
program pays for Medicare Part B premiums. To qualify, an
individual must:

Be eligible for Medicare Part A and Part B,

Have countable income less than 120% of the Federal
Poverty Level (in 2006, $980 per month, $1,320 for
couples)

Have assets at or below the limit ($4,000 for
individuals, $6,000 for couples)
Page 16 of 20

Meet Medi-Cal requirements besides income and assets
limits
The Qualified Invidiual-1 (QI-1) program pays for Medicare
Part B premiums. To qualify, an individual must:
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Be eligible for Medicare Part B
Have countable income between 120% and 135% of
the Federal Poverty Level (in 2006, between $980 and
$1,103 per month for individuals, and between $1,320
and $1,485 for couples)
Have assets at or below the limit ($4,000 for
individuals, $6,000 for couples)
Meet Medi-Cal requirements besides income and assets
limits
The Qualified Disabled Working Individual (QDWI) program
pays for Medicare Part A premiums. The QDWI program is for
Social Security Disability Insurance (SSDI) beneficiaries who lose
their SSDI and Medicare benefits due to earnings above the SGA
amount. To qualify, an individual must:

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



Be less than 65 years old
Still be disabled
Still be eligible for Medicare under a work incentive
program
Have income at or below 200% of the Federal Poverty
Level (in 2006, $1,634 per month for individuals,
$2,200 for couples)
Have assets at or below the limit ($4,000 for
individuals, $6,000 for couples)
Not be eligible for Medi-Cal
SSDI has rules that encourage you to return to work. After your
SSDI benefit ends, you will still receive free Medicare benefits for
93 months. After that period ends, you may want to consider the
QDWI program.
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Medi-Cal’s Health Insurance Premium Payment (MediCal/HIPP)
There are certain situations when Medi-Cal will pay for private
health insurance premiums. This program is for people who:




Are on Medi-Cal,
Also have private health insurance, or have private coverage
available,
Have a high cost medical condition, AND
Have lost (or are about to lose) private coverage
The idea is that when you lose your private insurance, Medi-Cal
can either pay for your medical expenses or pay for you to keep
your private coverage. Medi-Cal will do whichever costs less. If
you currently have private health insurance, the program is called
Health Insurance Premium Payment (HIPP). If you have private
coverage available, but aren’t using it, the program is called
Employer Group Health Plan (EGHP). Besides the difference in
names, the programs are otherwise identical and are usually
simply referred to as Medi-Cal/HIPP.
To qualify for the Medi-Cal/HIPP program, you must:



Be on Medi-Cal
Have no share of cost, or have one that is $200 or less
Have a high cost medical condition. This means that the
average Medi-Cal costs for treating your condition are more
than twice the cost of the monthly premium

For example, your premium is $100 and your costs for
treatment are $200

Have available, or be currently using, group health
coverage, COBRA, or a conversion policy. A conversion
policy is one where you converted a private group policy into
a private individual policy
Page 18 of 20





Apply for Medi-Cal/HIPP within 30 days of your coverage
ending (20 if you’re using a conversion policy)
Have a policy that covers your high cost medical condition
Not be Medicare eligible
Not part of a pre-paid or county health plan (County Health
Initiative, Geographic Managed Care, County Medical
Services Program)
Not be covered through the MRMIB program
Medi-Cal should evaluate your eligibility for Medi-Cal/HIPP when
you indicate that you have insurance available but haven’t
applied for it, that you are about to end your health insurance, or
that your policy has lapsed. To apply, you’ll need to provide forms
from your insurance company describing your benefit and a
diagnosis signed by your doctor.
If you are eligible for Medi-Cal/HIPP, you will still be on Medi-Cal.
The only change will be for those who did not have previously
have private coverage. If that’s the case, Medi-Cal will become
the payer of last resort. If you are accepted into the MediCal/HIPP program you must participate or else you can lose your
Medi-Cal eligibility. Your eligibility for the program is reevaluated
every year.
Other Information
Some examples of high cost medical conditions are AIDS,
asthma, cancer, diabetes, heart disease, paralysis, and
pregnancy. There are many others, and Medi-Cal evaluates
applications on a case-by-case basis.
Medi-Cal/HIPP will not pay for past premiums.
Medi-Cal/HIPP will pay for family members who aren’t on MediCal when it will save money for the state. For example, let’s say
that you have private health coverage that also covers your
family members. You are not on Medi-Cal, but your family
members are. If it saves the state money, Medi-Cal/HIPP will pay
Page 19 of 20
for your premiums so that your family members can be on the
private policy.
Sources
The following links are provided for those who want detailed
information on Medi-Cal. For those looking for more general
information, please go to Db101’s Medi-Cal Resources page.
The California Department of Health Services publishes their All
County Welfare Directors Letters online. They are organized by
year and by topic . Note that many of the Medi-Cal programs
addressed on this site are found under the “Disability” heading.
The Los Angeles Department of Public Social Services publishes
their Medi-Cal Policy guide online.
The Health Consumer Alliance (HCA) publishes brochures on
Medi-Cal. These are excellent resources for learning about MediCal programs, and provided source material for parts of this
page.
HCA and Protection and Advocacy, Inc. publish an “Overview of
the Medi-Cal System ”. This document includes references to
laws, regulations and court decisions on Medicaid and Medi-Cal.
Copyright © 2006 World Institute on Disability
Page 20 of 20
.