Medi-Cal, California’s version of Medicaid, is a state and federal program that offers free and low-cost coverage to those who qualify.
The program has undergone huge changes since the recent passage of the Affordable Care Act, one of the goals of which was to increase access to health insurance. Under the new rules, several million Californians will be phased in over the years as newly eligible for Medi-Cal coverage — most of them single adults ages 19 to 64 without children — in addition to the seven million already enrolled.
Who Is Eligible
Different eligibility requirements apply as new enrollees are phased in to Medi-Cal, depending on age and income; those enrolled in some other low-income benefit programs are automatically eligible for Medi-Cal.
Ages 19 to 64. Medi-Cal covers California adults who:
- Were former foster youth enrolled in Medi-Cal at age 18, until they turn 26
- Have incomes at or below $16,105 for an individual and $21,708 for married couples (138% of the federal poverty level)
“Income” is defined as adjusted gross income plus any tax-exempt income; to compute it, add lines 8b and 37 on a 1040 tax form. A person whose income is within those limits will get Medi-Cal coverage free until 2016, when they are slated to begin paying 10% of the cost.
Age 65 and older, blind, or disabled. Under former rules still in effect, Californians who are at least 65, blind, or disabled can qualify for Medi-Cal coverage if they have either:
- A low income and few assets and savings
- Personal resources reduced due to health care expenses
Income limit.This Medi-Cal income limit is calculated as a percentage related to federal poverty guidelines, which change every year. The current limit is about $1,188 monthly for an individual and $1,603 for a couple.
Asset limit. Individuals may own assets not worth more than $2,000; married couples may own $3,000 worth. But not all assets are included in the count. Exempt assets include:
- A primary home
- One vehicle
- Household items
- Personal belongings including clothing, heirlooms, and wedding and engagement rings
- Burial plots and any money in a designated burial plan fund
- Life insurance policies and the balance of pension funds, IRAs, and certain annuities
Higher limits for high medical expenses. Some people who have few assets but relatively high incomes may qualify for Medi-Cal if a designated amount goes exclusively to paying medical costs. This is called paying a “share of cost.” The amount may change with an individual’s monthly income.
Automatically eligible. Individuals enrolled in some programs automatically qualify for Medi-Cal.
- Supplemental Security Income (SSI) or State Supplementary Payment (SSP): Federal and state programs providing income to those 65 and over, blind, or disabled who meet income and resource limits. For a quick analysis of eligibility, use the SSI Benefit Eligibility Screening Tool.
- California Work Opportunity and Responsibility to Kids (CalWORKs): Provides income and services to some families with special needs. It is administered through the county social services department. Learn more through the Department of Social Services or apply for benefits online.
- Foster Care or Adoption Assistance Program: This program is run by California’s Children and Family Services Division.
- Refugee Assistance: Among other help, this program provides a limited time of Medi-Cal benefits to refugees, asylum seekers, and federally certified human trafficking victims. For more information, contact the local Office of Refugee Health.
Special categories. A number of additional specialized provisions make Californians in need of medical care eligible for Medi-Cal, including those who are any of the following:
- Under 21
- Residents in skilled nursing or intermediate care homes
- Parents or caretakers of disadvantaged children under 21
- Diagnosed with breast or cervical cancer
For more information on eligibility, contact the local county Medi-Cal office.
What Is Covered
All Medi-Cal plans must cover a base set of “essential health benefits”:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse services
- Prescription drugs
- Rehabilitation and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
In response to a strong consumer backlash after dental coverage was discontinued, some procedures —including x-rays, cleaning, exams, some root canals, crowns, and full dentures are also covered.
Those Eligible for Both Medicare and Medi-Cal
People who qualify for both Medi-Cal and Medicare benefits are known as “dual eligibles” or “Medi-Medis.” In California, this group generally has greater medical needs than the rest of the population, with most people having several chronic health conditions or disabilities requiring several services and supports. More than half have incomes of less than $10,000 per year.
In the past, the systems worked together fairly smoothly for dual eligibles: Medicare was considered the primary payer, with Medi-Cal providing secondary coverage to take up some of the slack, covering deductibles, copayments, some premiums, and the cost of some drugs Medicare does not cover.
But with the recent expansion of Medi-Cal, its higher income limits, and other differing eligibility rules, some risk losing Medi-Cal benefits when they reach age 65 and become eligible for Medicare; others face potential gaps in benefits or enrollment periods.
To ward off problems, Medi-Cal and Medicare have partnered to launch Cal MediConnect, a program to help coordinate care and keep people in their homes and communities rather than facilities when possible. Initially, Cal MediConnect will be tested in eight counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara.
Help in Paying for Health Insurance
Rules recently expanded under the Affordable Care Act mean that millions more Californians will qualify for Medi-Cal coverage. But some people with fairly low incomes may still earn too much to qualify. A couple more sources may help provide financial assistance to reduce the cost of health insurance they can purchase in the state marketplace, Covered California.
Premium assistance. The federal government offers a subsidy, applied when an individual enrolls in a Covered California insurance plan, to directly reduce the cost of monthly premiums. Premium assistance may be available to those who do not have affordable insurance through an employer or government program.
The amount of support available depends on a household’s size and income earned and is based on a sliding scale — more assistance for those with lower incomes. Individuals and families earning between 138% and 400% of the federal poverty level may be eligible. While the exact amount changes yearly, an individual earning up to about $46,680 or a couple earning up to $62,920 may still qualify for some premium assistance.
To check eligibility for Medi-Cal or monthly premium assistance, use Covered California’s Shop and Compare Tool.
Cost-sharing assistance. Cost-sharing subsidies, also based on income level and family size, reduce the amount paid out of pocket when medical care is given, such as copayments and co-insurance. This cost-sharing help may be available to those who earn about 2.5 times the federal poverty level — currently about $29,175 for an individual or $39,325 for a couple; the levels change slightly each year.
How to Apply
There are a number of ways to apply for Medi-Cal:
- Online using Covered California, which includes information about public and private health coverage options
- Online using BenefitsCal, which is the application portal for several state benefit programs for those with low incomes
- In person at the local county social services agency
- By completing a mail-in application form
Individuals applying for coverage based on a disability should contact the local Medi-Cal office.
If a person is homebound or living in a facility, the individual or family can request that a Medi-Cal representative visit and help complete the application.