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What is Medi-Cal?

Medi-Cal is California’s Medicaid program. Medi-Cal provides health insurance coverage to low-income Californians. There are several Medi-Cal programs with different eligibility requirements. The material presented in this section of the website provides information on Medi-Cal eligibility and benefits for adults who are elderly, age 65 and older, or who are younger adults with a disability.

To learn about other Medi-Cal programs, contact:

Maternal and Child Health Access
213-749-4261
www.mchaccess.org

Health Consumer Center
800-896-3203
www.nlsla.org

Covered California
800-300-1506
www.coveredca.com

Who is eligible for Medi-Cal?

Supplemental Security Income (SSI) linked Medi-Cal

The Supplemental Security Income (SSI) Program pays benefits to adults age 65 and older and to younger adults with a disability. To qualify for SSI, you must have limited income and resources. Persons who qualify for SSI benefits automatically qualify for Medi-Cal.

To qualify for SSI, you must meet the following income and resource guidelines:


The following types of unearned income are counted to determine eligibility for SSI:

  • Social Security benefits;
  • Pensions;
  • Unemployment benefits;
  • Disability benefits;
  • Rental income;
  • Help from family members and friends to pay for your living expenses;

What if I work? Will my earnings from my job be counted?

  • Yes, your earned income will be counted to determine eligibility for SSI. However, not all of your earnings will be counted.
  • You can deduct the first $65 of your monthly earned income.
  • You can then deduct half of the remaining amount.
  • SSI will only count the remaining amount.

Example: Eric is 65 and is applying for SSI. He has a job and earns $500/month. He receives no unearned income. How much of his earned income is counted?

Although Eric earns $500 per month from his job, only $217.50 is counted by to determine eligibility for SSI.


The following resources are not counted to determine eligibility for SSI:

  • The house you live in;
  • One vehicle, if it is used for transportation for you or a member of your household;
  • Household goods and personal belongings;
  • Burial plots or spaces for you or your immediate family;
  • A burial fund of up to $1,500 each for you and your spouse's expenses; and
  • Life insurance policy you own with a maximum face value of $1,500 or less per person.

The following resources are counted to determine eligibility for SSI:

  • Money in the bank;
  • A second home; and
  • Other property.

Where do I apply for SSI?

  • You apply for SSI at your local Social Security office.

If I receive SSI, do I also have to fill out a Medi-Cal application?

  • If you receive SSI benefits, you will get Medi-Cal automatically. You do not need to fill out a separate Medi-Cal application.
  • You should receive a Medi-Cal card in the mail.
  • You will continue to have Medi-Cal as long as you continue to receive SSI.

For more information about SSI, contact Social Security at 1-800-772-1213 or go to the Social Security website at www.ssa.gov/ssi.

What if I am not eligible for SSI? Can I still qualify for Medi-Cal?
  • Yes, you may be able eligible for other Medi-Cal programs if you are not eligible for SSI.

Aged & Disabled Federal Poverty Level Medi-Cal Program

If you are not eligible for SSI, you may be eligible for the Medi-Cal Aged and Disabled Federal Poverty Level (A&D FPL) Program. This program provides Medi-Cal coverage for elderly and disabled persons. To qualify for Medi-Cal under this program, you must meet income and resource limits.

This Medi-Cal program uses SSI guidelines to determine countable income and resources.

You can apply for this Medi-Cal program by Mail, In Person, or Online.

  • By mail, use a Single Streamlined Application, provided in English and other languages. Applications can be mailed to the Medi-Cal Mail-in Application Office at: P.O.Box 77267, Los Angeles, CA 90007-9819
  • In person at your local Department of Public Social Services (DPSS) office. Find the nearest County Office.
  • Online using the Department of Health Care Services website.

 

Medi-Cal with a Share of Cost (SOC)

Low-income adults who meet the SSI resource limits, but have incomes too high to qualify for the Aged and Disabled Federal Poverty Level Program may qualify for the Medi-Cal Aged, Blind Disabled Medically Needy Program, also known as Medi-Cal with a Share of cost.

The Medi-Cal “share of cost” works like a medical deductible. You must meet your share of cost each month before Medi-Cal will pay the balance of your medical expenses.

You can apply medical expenses or medical insurance premiums to meet or eliminate the Medi-Cal share of cost. Click here for more information on Medi-Cal with a Share of Cost.

What benefits does Medi-Cal provide?

Medi-Cal provides the following benefits to adults:

If I have Medi-Cal, do I have to join a Medi-Cal managed care health plan?

Most persons who have Medi-Cal are required to enroll into a Medi-Cal managed care plan.

Medi-Cal populations currently excluded from mandatory Medi-Cal managed care include persons who are:

  • Under age 21
  • Live in a VA nursing home
  • Live in a ICF/DD facility
  • Persons with other insurance (Employer Group Health Plan, Retiree health coverage, Veterans Administration)
  • Eligible for Medi-Cal with a share of cost and are not using Managed Long Term Services and Support (MLTSS) services.

Persons who have Medi-Cal as their only insurance may request a medical exemption to stay in fee-for-service Medi-Cal.

Persons who have Medicare and Medi-Cal do not qualify for a medical exemption to stay in fee-for-service Medi-Cal.

The Medi-Cal managed care health plans serving Los Angeles County are:

To enroll into a Medi-Cal managed care health plan or to switch to a different plan call Health Care Options, the Medi-Cal enrollment broker at 844-580-7272.

If I have Medicare and Medi-Cal, how does the insurance coverage work together?

When you have Medicare and full Medi-Cal, Medicare is your primary insurance and Medi-Cal is your secondary insurance.

As your secondary insurance, Medi-Cal:

  • Pays your Medicare Part A and B copayments and deductibles.
  • Provides benefits not covered by Medicare such as dental care, hearing aids, long term care in a nursing home and at home, incontinence supplies and non-emergency medical transportation to medical appointments.
  • Pays your Medicare Part B premium ($134/month in 2018).
  • Qualifies you for the full financial assistance with your Medicare prescription drug coverage under the Medicare Part D Low-Income Subsidy Program.

For more information on how Medicare and Medi-Cal work together, click here: Medicare and Medi-Cal: Learn about your health care options.

Will Medi-Cal help pay for my nursing home stay?

Medi-Cal Long-Term Care (LTC) program eligibility guidelines make a distinction between a single person and a married couple.

For a single person, the resource limit is $2,000 and the SSI resource rules are used to determine eligibility.

Under Medi-Cal LTC rules, a single person's monthly income is applied toward the nursing home monthly income cost minus a $35 needs allowance. This is the individual's Medi-Cal monthly share of cost for the nursing home stay.

Example: Don is divorced with a Social Security income of $1,500/month. Don has less than $2,000 in the bank and owns no property.

In this example, Don's Medi-Cal LTC nursing home share of cost is $1,465 ($1,500- $35 needs allowance). Don keeps $35 of his monthly income each month for his personal needs and the $1,465 balance is applied to his monthly nursing home costs.

See the next section for Medi-Cal Long Term Care rules for a married couple.

What are the Medi-Cal Long Term Care eligibility rules for married couples?

Medi-Cal Long Term Care eligibility requirements are more liberal for married couples in order to protect a certain level of income and assets for the community spouse who remains at home.

California law permits the community spouse to keep a certain level of countable resources at the time of application called the "community spouse resource allowance or CSRA." In 2018, the CSRA is $123,600. Countable resources above the $123,600 limit are counted toward determining the nursing home spouse's eligibility for Medi-Cal.

Medi-Cal long term care rules also permit the community spouse to keep a monthly income, which is called a "maximum monthly maintenance needs allowance or MMMNA." In 2018, this income amount is $3,090. Medi-Cal long term care rules permit the community spouse to keep any income that is received in his/her name even if it exceeds the MMMNA.

These Medi-Cal long term care spousal protections also apply to same-sex spouses and registered domestic partners.

For more information on Medi-Cal Long term care contact California Advocates for Nursing Home Reform (CANHR) at (800) 474-1116.

What is Medi-Cal Estate Recovery?

The Medi-Cal program seeks repayment from the estates of certain deceased Medi-Cal beneficiaries. Repayment only applies to Medi-Cal benefits received by beneficiaries on or after their 55th birthday and who own assets at the time of death.

For Medi-Cal members who die on or after January 1, 2017:

  • Medi-Cal repayment is limited only to estate assets subject to probate that were owned by the deceased member at the time of death.
  • Repayment is limited to Medi-Cal payments made for managed care premiums paid, nursing facility services, home and community based services, and related hospital and prescription drug services.

For more information about Medi-Cal Estate Recovery, see: Medi-Cal Estate Recovery.

What does the Medi-Cal Hearing Aids Benefit cover?

To obtain a Medi-Cal covered hearing aid, you must first have an audiology exam or hearing test to determine if you need a hearing aid. The audiology exam is not covered by Medi-Cal but is covered by Medicare.

In addition, you must obtain a prior authorization from Medi-Cal or your Medi-Cal managed care health plan to use Medi-Cal coverage to obtain a hearing aid. You must use a hearing aid vendor who is a Medi-Cal provider. If you are enrolled into a Medi-Cal managed care health plan, you will be referred to a hearing aid vendor that contracts with your plan.

The Medi-Cal hearing aid benefit for adults has an annual cap of $1,510 per fiscal year (July-June) that includes the cost of hearing aids, supplies, repairs, initial set of batteries and visits to the hearing aid vendor. The hearing aid cap does not apply to Medi-Cal nursing home residents.

If the hearing aid cost is more than $1,510, the vendor cannot bill Medi-Cal and bill you for the balance of the cost. This is considered balanced billing.

 

The cost of replacing your hearing aid(s) if they are lost, stolen or irreparably damaged due to circumstance beyond your control is not included in the $1,510 maximum benefit cap. However, you must meet certain requirements in order to receive replacement hearing aids if the cost exceeds the annual limit. For example, if the hearing aid is damaged, you must provide a detailed explanation regarding how the damage occurred and the statement must be signed by your doctor. If the hearing aid was stolen, you must provide a copy of a filed police report.

Learn more about Medi-Cal's hearing aid benefit.

 

Does Medi-Cal pay for Incontinence Supplies?

You must obtain prior authorization from Medi-Cal or your Medi-Cal managed care health plan before you can use this Medi-Cal benefit. You will also need a prescription from your physician that explains the medical condition causing the incontinence and the type of incontinence supplies you need.

Medi-Cal covered incontinence supplies include: disposable adult briefs/diapers, protective underwear, under pads, shields, liners.

What are the Medi-Cal dental benefits for adults?

Medi-Cal covers the following dental procedures:

  • Exams and x-rays
  • Cleanings
  • Fluoride treatments
  • Fillings
  • Anterior root canals (front teeth)
  • Prefabricated crowns (stainless steel or tooth colored)
  • Full dentures
  • Deep cleanings (scaling and root planing)
  • Laboratory crowns
  • Partial dentures and partial denture adjustments, repairs and relining
  • Root canals in back teeth 

* The highlighted benefits are newly covered starting January 2018.

There are two ways to obtain Medi-Cal dental benefits:

  1. Enroll in a Medi-Cal dental plan: You use a specific network of dental providers available through your plan. Your dental services must be authorized by your plan. Dental plans in L.A. County: Health Net, Liberty Dental Plan, and Access Dental Plan
  2. Denti-Cal: Obtain dental services from any Medi-Cal dental provider. Dental services must be authorized by Denti-Cal.

Call the Denti-Cal Beneficiary Hotline at 1-800-322-6384 for:

  • Help locating a Medi-Cal dentist;
  • Questions about Medi-Cal dental coverage or prior authorization;
  • To file a grievance or complaint against a dentist.

To appeal a Medi-Cal dental authorization denial, call 1-800-952-5253 to request a fair hearing.

What is Medi-Cal’s new Non-Medical Transportation Benefit?

Medi-Cal now covers transportation by car, taxi, public transportation or other private vehicle when you need transportation to get any Medi-Cal covered services, such as medical or dental appointments.

This new transportation can also be used to pick up prescriptions at the pharmacy or medical supplies.

Who is eligible for this transportation benefit? 

You must meet one of the following requirements:

  • You do not have a driver's license or a working car; or
  • You cannot travel alone to a medical or dental services; or
  • You have a physical or mental limitation and cannot travel by public transportation.

Are there other requirements to use the transportation benefit? 

  • The transportation services must be authorized by Medi-Cal. If you are in a Medi-Cal health plan, the plan must authorize transportation services.
  • If you cannot travel alone, Medi-Cal will cover transportation for someone to travel with you, such as a spouse, parent or guardian.

Who do I contact to get these transportation services?

  • Call your Medi-Cal health plan member services phone line.