PROGRAM

MEDI-CAL GENERAL PROVISIONS

California’s Medicaid program is called “Medi-Cal.”  The Medical Care Services Division of the Department of Health Services (DHS) administers the program, contracts with vendors for fiscal services, dental care, managed care outreach and enrollment, and data management. 

Eligibility is determined by County Health and Welfare Departments.  These departments conduct eligibility determinations, enrollment and recertification; implement state policy changes; and outstation eligibility workers in community sites. 

Medi-Cal is bound by a lawsuit known as Sneede.  This lawsuit limits Medi-Cal financial responsibility to a parent for a child and a spouse for a spouse.    If Sneede applies, the income/property limits for certain children in a family may be lower than those listed for the entire family under the program in question, e.g., the FPL is for the entire family size, even though only the income of the infant/child, his or her parents, and if applicable, the spouse is counted.

NOTE:  The following eligibility requirements are given as if everyone to whom the chart applied is an applicant and therefore receives only applicant deductions.

MEDI-CAL ELIGIBLITY CATEGORIES

Pregnant Women

Presumptively eligible.

Pregnant women may be considered presumptively eligible, if they appear to be income eligible, until the application process for Medi-Cal is complete.  If otherwise eligible for Medi-Cal, she is placed in another eligibility category.  Whether or not her Medi-Cal application is approved, providers are still reimbursed for the services provided, and the state receives federal matching funds.  However, the presumptive eligibility program does not pay for labor and delivery.

Pregnant women – Income disregard program

Income 200% of FPL or less.

No asset limit.

May receive pregnancy-related services only.

This group may instead be eligible under 1931(b) – see section below, or under Medically Needy (MN) or Medically Indigent (MI).

May have a Share of Cost under an MN or MI aid code for non-pregnancy related services.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

Women in this program automatically receive Medi-Cal coverage for 60 days postpartum.

60-Day Postpartum Program

Women who received Medically Indigent and Medically Needy Medi-Cal with a share of cost when they were pregnant or who were no longer eligible for full scope benefits.

60 Day Postpartum” is a program for Medically Needy or Medically Indigent women who have a Share of Cost or whose pregnancy ended and they have no other basis for Medi-Cal eligibility.  It allows them to continue to receive Medi-Cal for 60 days following birth.

Note: 60 Day Postpartum is already included in the program for women in the 200% of FPL or less program.

60-Day Postpartum coverage is included in the income disregard program for pregnant women.

Infants up to age 1 – Income Disregard Program

Income 200% of FPL or less.

No asset limit.

Those with low income in this group may instead be eligible under 1931(b) – see section below, or under no share of cost Medically Needy (MN), Medically Indigent (MI) or other program.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

Children age 1 through age 5 – Income Disregard Program

Income 133% of FPL or less.

No asset limit.

Those with lower income in this group may instead be eligible under 1931(b) – see TANF section below, or under No Share of Cost Medically Needy, Medically Indigent or other program.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

Children age 6 through age 18 – Income Disregard Program

Income 100% of FPL or less.

No asset limit.

This group may instead be eligible under 1931(b) – see TANF section below, or under no share of cost Medically Needy, Medically Indigent or other program.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

Minor Consent Services (children under age 21)

Income 200% of FPL less, if pregnant OR can be considered 100% FPL, Medically Needy or Medically Indigent with or without a Share of Cost OR may be considered 1931(b).

Tuberculosis Program

·         Must be infected with TB.

·         Must not be a Medi-Cal beneficiary whose coverage is mandated by federal laws.

·         Must be a citizen of the U.S. citizen or a person who has satisfactory immigration status.

·         Must have income and resources which do not exceed the maximum amount for a disabled individual under the SSI program.

·         Must meet all other Medi-Cal requirements.

TB Medi-Cal is an optional program for persons infected with tuberculosis whose income and resources do not exceed the maximum amount for a disabled individual.  The determination of whether an individual is TB infected shall only be made by a Medi-Cal physician.  Department of Health Services has developed a Tuberculosis Application form which includes a section for these physicians to use to certify TB infection. 

Medi-Cal clinics and Medi-Cal providers are encouraged to assist potential recipients in applying for Medi-Cal.  This is an alternative to applicants applying directly at the county office.  These providers may help applicants complete all initial Medi-Cal forms used in the application process and may gather application verification information.  This information will then be forwarded to the county welfare department for a Medi-Cal determination.

Dialysis and Total Parenteral Nutrition (TPN) Programs (State Only)

No fixed income/asset limit.  Clients pay on a sliding scale according to countable income and assets.

The Dialysis and TPN Programs are designed for people who do not qualify for disability and therefore, do not qualify for Medi-Cal.  These programs are available to people with higher incomes and resources in order that they may avoid impoverishment due to their medical condition and facilitate their ability to continue working.  These individuals do not receive full Medi-Cal benefits, but only those to treat the specific disease/condition for which they are qualified.

Documented and undocumented aliens

Must qualify through any eligibility category.

Aliens with satisfactory immigration status who qualify for Medi-Cal are entitled to the full range of benefits.  Those without satisfactory immigration status are entitled only to emergency, pregnancy-related services, or long term care, if appropriate.

Public Assistance Linked/AFDC/TANF (CalWORKS) ELIGIBILITY CATEGORIES

The welfare-to-work program in California is called California Work Opportunity and Responsibility to Kids (CalWORKs).  Recipients automatically receive Medi-Cal.

Section 1931(b).

This includes children up to age 18 (age 19 if child is enrolled in school and is expected to graduate by age 19), pregnant women*, and parents/caretakers of deprived eligible children.

*Pregnant women with no other deprived children must be in their last trimester.

Income limits for applicants of the 1931(b) program are set at 100% of FPL for the applicable family size.

Asset limits:

The 1931(b)-only option also covers families that decide not to enroll in CalWORKs even though they may be eligible for assistance.

There is a $240 deduction for 1931(b) applicants with certain types of disability-based income and the poverty levels increase each year.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

An individual’s home and one car (within certain limitations) are exempt from asset calculations.

Applicants and recipients have different income and asset limitations.

Transitional Medi-Cal (TMC)

May continue to receive Medi-Cal for up to 24 months

If recipients stop receiving CalWORKS or 1931(b) Medi-Cal due to increased earnings, they may qualify for TMC for up to 24 months.  The first 12 months of coverage is federal/state funded, while the last 12 months is state funded only and covers only individuals age 19 and older.  Children can usually qualify for other Medi-Cal programs during this time.

People transitioning off cash assistance are placed in a transitional aid code while their eligibility for other Medi-Cal coverage is determined.

Four-Month Continuing Medi-Cal

May continue to receive Medi-Cal for 4 months.

If recipients stop receiving CalWORKS or 1931(b) due to receipt of child support or alimony, they may qualify for four months of continuing Medi-Cal.

Foster Care or Adoption Assistance Program

Automatically eligible for Medi-Cal.

Children who receive foster care benefits also receive Medi-Cal.  Some children in foster care and the Adoption Assistance Program receive cash-related Medi-Cal, while some receive their Medi-Cal coverage through the Medically Indigent Program, depending on the child’s income.

MEDI-CAL “MEDICALLY NEEDY” ELIGIBLITY CRITERIA

Individuals and families with incomes too high to qualify for cash assistance or 1931(b) but who otherwise qualify for CalWORKS or SSI/SSP, or who do not wish to receive cash assistance.

This includes deprived children up to age 21, pregnant women, parents/caretakers of deprived eligible children and aged, blind and disabled.

Unlike property, income is not a bar to eligibility.  Income above

Medically Needy Maintenance Need Levels (MNL) requires a Share of Cost (see next column).

MNLs are as follows:

Individuals must meet SSI requirements of age, blindness or disability or the AFDC requirements of deprivation to be eligible for Medically Needy Medi-Cal (e.g., 65+, disabled, blind, children who meet deprivation requirements, parents and caretakers of these deprived children, and pregnant women).

Asset limits are the same as those for 1931(b) except that the limit for one person is $2,000 rather than $3,000.  See above for asset limits for families of two or more.

Those who receive Medically Needy Medi-Cal may be eligible with or without “share of cost.”  Share of cost refers to the amount of health care expenses a recipient must incur before Medi-Cal begins to offer assistance.  Whether or not a recipient has a share of cost, and the level of that cost, is determined by monthly family income.

Most common income deductions for pregnant women, children and parents/caretakers: $90 work-related expense and dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

Most common income deductions for aged, blind and disabled: $20 any income deduction, $65 and ½ earned income deduction, dependent care deduction.

An individual’s home and one car (within certain limitations) are exempt from asset calculations.

“Deprivation” exists when a parent:

·         Is absent from the home; or

·         Is incapacitated (unable to work or care for children); or

·         Is disabled; or

·         Is deceased; or

·         Is employed less than 100 hours per month; or

·         Has net family earnings that are at or below 100% of FPL.

Under “Share of Cost” Medi-Cal, beneficiaries must pay an amount equal to their share of cost toward their medical expenses each month before Medi-Cal coverage begins.

MEDI-CAL “MEDICALLY INDIGENT” ELIGIBILITY CATEGORIES AND CRITERIA

Eligibility Categories:

·         Pregnant women and children under age 21 who do not meet Medically Needy deprivation requirements

·         Children in foster care who have excess income for a cash grant

·         Nursing facility residents age 21 through 65 who do not have disabilities or any other “linkage”

·         Individuals without satisfactory immigration status who are in need of nursing home care

·         Extended Medi-Cal for former Foster Care children up to age 21 who do not live with a parent.

All Medically Indigent categories have the same financial criteria as the Medically Needy category (see above).

Asset limits are also the same as those for the Medically Needy category.  See above.

Must have been in foster care on 18^th birthday.

Although the federal government does not require states to offer Medicaid Medically Indigent (MI) programs, California has opted to have an MI program within Medi-Cal.  The state receives federal funding for children and pregnant women in the MI program*, but Long Term Care adults are state-funded only.

*Federal rules categorize pregnant women and children as Medically Needy.

Most common income deductions: $90 work-related expense, dependent care deduction of up to $200 for infants up to age 2 or a disabled dependent or up to $175 for a child age 2 or older.

An individual’s home and one car are exempt from asset calculations.

There is a Medi-Cal Medically Indigent (MI) program as well as a county Medically Indigent Adult (MIA) program.  The county MIA program is not Medi-Cal.  Some counties call their programs “County Medical Services Program” (CMSP).

Coverage for the Medi-Cal MI program may or may not have a share of cost depending on family income.

Elderly/Disabled

SSI/SSP Recipients

Automatically eligible for Medi-Cal.

The SSI allowance for assets is $2,000 for an individual and $3,000 for a couple. 

“Pickle” (people who lose SSI/SSP due to COLAs)

Medi-Cal (No Share of Cost) benefits are provided to any aged, blind or disabled person or couple meeting all of the following:

1.      The person currently receives Title II RSDI, Social Security Benefits;

2.      Since April 1997, the person has received and been entitled to receive both RSDI and Title XVI, SSI/SSP benefits in the same month;

3.      The person has been discontinued from SSI/SSP for any reason;

4.      The person has received an RSDI Cost of Living increase in any month since SSI/SSP was discontinued; and

5.      The person would be entitled to receive SSI/SSP benefits if the RSDI COLAs received after SSI/SSP ineligibility are disregarded.

Aged and Disabled Federal Poverty Level (A&D FPL) Program

Income limit is at or below 100% of FPL and asset limitations are the same as the Medically Needy category.

Program provides No Share of Cost Medi-Cal to eligible recipients.

There is a $230 income disregard for individuals and $310 income disregard for couples applying for this program.

There is a 65+ age limit for this program.  Children are eligible if disabled.

Disabled Widow(er)

May continue to receive Medi-Cal.

OBRA ’87 amended the Social Security Act.  This amendment allows widow(er)s between the ages of 60 and 64, who lose SSI/SSP benefits as a result of becoming entitled to or receiving an increase in Title II benefits (early widow(er)s benefits), to continue their Medi-Cal eligibility until they become eligible for Part A of Medicare.  Eligibility under this provision was effective July 1, 1988.

OBRA ’90 is the expansion of the 1987 Disabled Widow(er)s (DW) program to include certain Disabled Widow(er)s and surviving divorced spouses ages 50-59 who are disabled and lose SSI/SSP benefits due to a receipt of Title II DW and certain Title II benefits.  They are to be deemed SSI recipients for Medi-Cal until they are entitled to Medicare Part A.

In-Home Support Services (IHSS)-residual

Personal Care Services (PCS) for aged, blind and people with disabilities

a)      For PCS: Receives full scope Medi-Cal under a program that does not restrict or limit services and meets the “needs” requirements to receive PCS.  A parent may not be a provider for a minor child and a spouse cannot be the other spouse’s provider.

b)      IHSS-residual:  Generally must meet SSI requirements and meet the “needs” requirements to receive IHSS residual.

PCSP pays for services provided in the home that enable aged, blind and/or disabled recipients to remain in the home and not be placed in Long Term Care. 

IHSS is a state-only program that provides the same services as PCS, but those services are provided by a parent or spouse under certain other restricted conditions.  IHSS recipients receive Medi-Cal.

PCSP is a Medi-Cal program benefit.  The assessment of the need for services is provided by the California Department of Social Services IHSS program.  Coordination between Medi-Cal and IHSS is necessary to determine eligibility for PCS.

Disabled Adult Child/Children (DAC)

To be eligible, these individuals must be at least 18 years old and have previously received SSI/SSP on the basis of blindness or a disability which began before the person reach age 22.  They must also:

1.      Currently receive Retirement, Survivors, and Disability Insurance benefits as a result of this blindness or disability, and

2.      Have been discontinued from SSI/SSP as a result of entitlement on or after July 1, 1987 or Social Security child benefits based on disability before age 22 or because of an increase in child disability benefits.

Disabled Adult Children are people who were born with some kind of disabling condition, or who became disabled before age 22.  Disabled Adult Children can claim Social Security benefits from a parent’s or grandparent’s work history, which can entitle them to substantially more money than claiming on their own work history.  To allow DAC individuals to continue their “no share of cost” Medi-Cal coverage, this Title II income is disregarded when calculating Medi-Cal eligibility.

Long Term Care

Personal Needs limit: $35/month

Resource limit: $2,000

Spousal impoverishment rules apply.

The income limit applies to residents of long-term care facilities.

Individuals in long term care with a spouse at home have special deeming rules called “Spousal Impoverishment.”  They are allowed to give a certain amount of income and resources to the spouse at home.

250% Working Disabled

Income below 250% of FPL.  Must continue to meet the federal definition of disability, even though able to work.  Must meet SSI requirements but earnings are exempt. Disability income is disregarded.

Retirement accounts are an exempt asset.

The 250 Percent Working Disabled program allows individuals to buy-in to Medi-Cal by paying monthly premiums on a sliding scale.  Premiums range from a minimum of $20 to a maximum of $250 per month for individuals and $30 to $375 per month for couples.

Medicare Buy-In Programs:

·         Qualified Medicare Beneficiary (QMB)

·         Special Low Income Medicare Beneficiary (SLMB)

·         Qualifying Individual (QI-1)

·         Qualifying Individual (QI-2)

Qualified Disabled Working Individual (QDWI)

Income at or below 100% of FPL .

Asset limit:  Twice the SSI allowance.

Income at 100% and up to but not including 120% of FPL.

Asset limit:  Twice the SSI allowance.

Income at 120% and up to but not including 135% of FPL.

Asset limit:  Twice the SSI allowance.

Income at 135% and up to but not including 175% of FPL.

Asset limit:  Twice the SSI allowance.

Only the Medi-Cal payment of Medicare Part A premiums for working people who have lost entitlement to free Part A benefits due to substantial employment, as defined by the Social Security Administration.  Income must be below 200% of FPL and assets below twice the SSI allowance.

For QMBs, Medi-Cal pays Medicare deductibles, coinsurance and premiums.

For SLMBs and QI-1’s, Medi-Cal pays Medicare Part B premiums. 

For QI-2s, Medi-Cal annually reimburses a portion of the Medicare premium ($3.91 per month at this time).

The SSI allowance for assets is $2,000 for an individual and $3,000 for a couple.  The asset limit for Medicare Buy-In programs (QMB, SLMB, QI, QWDI) is twice the SSI allowance (e.g., $4,000 for an individual and $6,000 for a couple).

Home and Community Based 1915(c) waiver programs

No parental income/resources are counted for a child.

Spousal impoverishment rules apply to adults.

Income and property limits are equal to applicable program.

S-CHIP

Children under age 19

Income 250% of FPL or less.

No asset test.

The program is called “Healthy Families”.

The monthly premium is determined by income category, which includes family size, family income and the chosen health plan.  Monthly premiums range from $4 to $9 for each child, up to a maximum of $27 for all children in a family enrolled in the Healthy Families program.

All children in a household must be enrolled in the same plan.

Premiums are waived for individuals of American Indian or Alaska Native decent.

Copayments are $5 for children.  Maximum coinsurance is $250 per year.

Some mental health services are carved-out.

Individuals must be uninsured for at least 3 months, unless the loss of coverage was due to:

·         Job loss or job change; or

·         The family moved into an area where employer-sponsored coverage is not available; or

·         The employer discontinued health benefits to all employees; or

·         Coverage was lost because the individual providing the coverage died, legally separated or divorced; or

·         Health coverage was provided under a federal COBRA policy and the COBRA coverage ended; or

·         Reached the maximum coverage of benefits allowed in the current insurance in which the person is enrolled.

Children (under age 19) may not be eligible for no-cost Medi-Cal.

Minors who do not live with parents, legal guardians, stepparents, foster parents or caretaker relatives may be eligible for the program for themselves or their children if they meet all other requirements.

Children who no longer qualify for “no share of cost” Medi-Cal, but who appear to be eligible for the Healthy Families (HF) Program, are continued on Medi-Cal for one additional month.  This is called the Bridge program.  During this time period, if the beneficiary has not indicated that the HF program is not wanted, the county will forward their most current application and supporting documents to HF.  HF will then contact the family with enrollment information.