PURPOSE

Medically Needy Medi-Cal is an eligibility category (program) for California residents, under 65, who meet its disability and financial eligibility requirements. An individual may consider applying for this program when their income is too high to be eligible in SSI-Linked or Aged and Disabled Federal Poverty Level Medi-Cal. This coverage may require the individual to incur a monthly co-payment known as a share of cost.

MEDICAL ELIGIBILITY

An individual, under age 65, must meet Social Security’s medical rules for disability.

FINANCIAL ELIGIBILITY

Asset Requirements

An individual may not have liquid assets (accessible money) in excess of $2,000 ($3,000 for a couple). Ownership of one house, occupied by the individual, and one car will not be considered when determining the individual’s resource levels.

Income and Earnings

Under Medically Needy Medi-Cal, the individual is the initial payer for health services, up to a fixed monthly limit called the share of cost. The share of cost incurred by an individual in a given month is the amount by which the individual’s total countable income minus any Health Benefit Plan Payment Premiums exceeds $600 ($934 for a couple). See below for an explanation of how to determine your eligibility and share of cost for this program.

Payment of the monthly share of cost amount is a financial arrangement between the individual and the provider, not Medi-Cal. Medi-Cal pays for all other approved Medi-Cal services that month.

Individuals applying for Medically Needy Medi-Cal with unpaid medical bills may be able to reduce their future share of cost expenses. This reduction is authorized by case law known as Hunt v. Kizer.

Program enrollees living with HIV/AIDS may be eligible to have the AIDS Drug Assistance Program (ADAP) cover the share of cost amount if they meet ADAP requirements and use ADAP approved prescriptions.

RESIDENCY REQUIREMENT

An individual must be a legal United States and California resident. Current provisions regarding immigrants can be found in the federal Welfare Reform Act.

Medi-Cal uses the same residency requirement rules as Social Security. The Supplemental Security Income (SSI) program provides an explanation of the rules on the Social Security Administration website.

BENEFIT

This eligibility category of coverage allows the recipient to participate in full-scope Medi-Cal and access additional Medi-Cal programs such as:

• Medi-Cal’s Health Insurance Premium Payment program (Medi-Cal/HIPP) if the individual’s share of cost is $200 or less;
• Medi-Cal’s co-pay and premium payment programs for Medicare beneficiaries (QMB, SLMB, Q-1, Q-2, and QDWI); and
• In-Home Supportive Service (IHSS) if found eligible for these services by means of a needs assessment. Enrolling through IHSS may be more cost effective when an individual has a share of cost using Medically Needy Medi-Cal.

The Centers for Medicare and Medicaid Services (CMS) provide an explanation of many of the services covered by full-Scope Medi-Cal (Medicaid) on their website under the heading of Scope of Medicaid Services.

INTEGRATION

If an individual has other health coverage, Medi-Cal (in all eligibility categories) becomes the secondary payer. In this case, the other health coverage must be used before Medi-Cal coverage is available to supplement that coverage.

APPLICATION

The processing of an application takes an average of between 30 to 60 days from the date of application. An eligibility worker may enroll an individual without conducting a medical determination of disability if the individual already has met the medical rules for disability. For example, a Social Security Disability Insurance (SSDI) beneficiary has already met the medical rules for this program.

Medi-Cal currently provides a printable application in eleven languages online which can be mailed after being completed.

Information regarding local Medi-Cal offices and telephone numbers can be obtained on the California Department of Health Care Services website or by calling the Beneficiary Unit for Medi-Cal, 916-636-1980.

RETROACTIVE PAYMENTS

Medi-Cal can pay medical bills incurred up to three months prior to the application date. The exception is when an individual has unpaid medical bills and uses the Hunt v. Kizer provision.

ADDITIONAL INFORMATION

There are a limited number of doctors who accept new Medi-Cal patients. Treatment and prescription limitations may exist.

Medi-Cal has the ability to recover costs from the estates of deceased individuals over age 55.

Medi-Cal/HIPP, a Medi-Cal program, exists to help qualified individuals pay their private health insurance premiums if their monthly share of cost is $200 or less.

As an individual’s circumstances change, it is important to review the most cost effective eligibility category of Medi-Cal available. Here are five additional Medi-Cal eligibility categories:

1. SSI-linked Medi-Cal is medical coverage an individual automatically receives if he or she qualifies for a cash benefit from Supplemental Security Income (SSI). When an individual receives no SSI cash benefit due to earnings, Medi-Cal coverage may continue under Social Security’s 1619(b) provisions.

2. Aged and Disabled Federal Poverty Level Medi-Cal is medical coverage for which an individual qualifies at no cost if his or her total countable income minus a Maintenence Need Allowance is not more than $1,047 for an individual or $1,472 for a couple for 2006.

3. Breast and Cervical Cancer Treatment Program (BCCTP) is a Medi-Cal program, available as of February 2002, for California residents with a diagnosis of breast or cervical cancer and who meet financial eligibility criteria.

4. In-Home Supportive Services (IHSS) is a Medi-Cal program that provides personal assistance services an individual can use to live at home or maintain employment safely.

5. 250% California Working Disabled (CWD) program allows disabled workers to buy into Medi-Cal health coverage by paying a monthly premium.