DB101 California - Medi-Cal: Medi-Cal Categories (2024)

Income-based Medi-Cal

Medi-Cal is a major government-funded health program that helps people with low income.

The simplest way to qualify is if you:

• Live in California
• Don't qualify for Medicare

And you are in one of these situations:

• You are 19-64 years old and your family’s income is at or below 138% of the Federal Poverty Level (FPL) ($20,783 for an individual; $43,056 for a family of four).
• You are a child 18 or younger and your family’s income is at or below 266% of FPL ($82,992 per year for a family of four).
• You are pregnant, and your family’s income is above 138% of FPL, but at or below 213% of FPL ($43,537 if you are single and pregnant with your first child, $66,456 per year for a family of four; the unborn baby is counted as a member of the pregnant woman's family). This is called Medi-Cal for Pregnant Women and it covers pregnancy-related services, including prenatal care, labor, delivery, postpartum care, and family planning services. It may also cover services for any other medical condition that is medically necessary for the woman.
  

Income-based Medi-Cal counts most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medi-Cal eligibility.

If you are in these situations, there are is no limit to how much money or other resources you have and it does not matter whether or not you have a disability.

Medi-Cal for People with Disabilities

People with disabilities have more ways they can qualify for Medi-Cal if they don't meet the standard eligibility rules described above. For example, if you have a disability, you may qualify for Medi-Cal even if you have higher income or are on Medicare. The main additional ways to qualify are:

• (A&D FPL)
• SSI-linked Medi-Cal and SSI 1619(b)-linked Medi-Cal
• Medi-Cal's Working Disabled Program, and
• (ABD–MN)

These ways to qualify are explained here.

No more Medi-Cal/MSP resource limits

Medi-Cal and immigrants

Aged & Disabled Federal Poverty Level Medi-Cal (A&D FPL).

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:

• Be either aged (65+), or disabled (meet Social Security’s definition of disability, even if your disability is blindness)

• Have less than $1,732 in countable monthly income for an individual ($2,351 for a couple).

If you are single and live on your own, follow these steps to figure out if your countable income makes you eligible for A&D FPL Medi-Cal. If you live with others, you should use DB101's Benefits and Work Estimator.

1. Find your total countable income using Social Security’s rules.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Impairment Related Work Expenses (IRWEs)	$
Your Monthly Countable Income

Note: If you are blind, subtract any money you use for Blind Work Expenses (BWEs) from this amount.

2. 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 Level. Maintenance Needs Levels are listed in the table below. Subtract this amount from your total countable income:

3. Subtract any health insurance premiums that you pay. These include Medicare, health, vision, and dental insurance premiums.
4. If you are living in a board and care facility, subtract $315.

The number you get is the amount of monthly income that is counted for the A&D FPL program. If it is less than $1,732 for individuals or $2,351 for a couple, then you qualify for free, full scope Medi-Cal based on A&D FPL rules.

If it is higher than $1,732 for individuals, you may qualify for Medi-Cal's Working Disabled Program or ABD-MN Medi-Cal instead.

Aged, Blind, & Disabled Medically Needy Medi-Cal (ABD–MN)

If you cannot qualify for free Medi-Cal or Medi-Cal's Working Disabled Program (described below), you may be able to get Medi-Cal through the Aged, Blind, & Disabled - Medically Needy (ABD–MN) program. However, you would 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.

A share of cost can be expensive

Your ABD-MN Medi-Cal share of cost could be very high. In most cases, it would be cheaper for you to get Medi-Cal's Working Disabled Program or even for you to get an individual plan with government subsidies on Covered California. Medi-Cal's Working Disabled Program is described below and you can read more about individual plans in DB101's Buying Health Coverage on Covered California article.

If you are single, you can figure out your share of cost by following the first step for calculating A&D FPL eligibility. After Step 1, take your countable income and subtract the MNL for your family size including yourself and also subtract any health, dental, or vision insurance premiums you pay each month. The resulting figure is your share of cost each month. If you get a number that is 0 or less, then you have no share of cost. You only have to pay a share of cost in months when you have medical expenses.

There are good factsheets translated into a several languages about how your share of cost works.

Example

SSI-Linked Medi-Cal

If you get Supplemental Security Income (SSI), a benefit for people with low income who are aged, blind, or disabled, you get Medi-Cal automatically. You don’t have to fill out any additional paperwork. Read DB101’s SSI article for more information about whether you qualify for SSI.

Staying on Medi-Cal through SSI 1619(b) if Your SSI Benefits End

If your SSI benefits go to zero because you go back to work, an SSI rule called 1619(b) lets you to keep your Medi-Cal coverage if you:

• Were eligible for SSI benefits for at least 1 month
• Need Medi-Cal coverage to keep working
• Still meet all the other SSI requirements, such as being disabled, having resources below $2,000, and
• Make less than $58,638 in gross income per year.
  • Note: If your earnings are over this limit and you have high medical expenses, you might still qualify for 1619(b). Ask your local Social Security office about the 1619(b) Individualized Earnings Threshold.

For additional information, read the DB101 SSI article, check out Social Security’s webpage on 1619(b), or talk to a benefits planner.

Note: If you don’t qualify for Medi-Cal through 1619(b) because your income is too high, you may qualify for Medi-Cal's Working Disabled Program.

Example

Medi-Cal's Working Disabled Program

If you are working, disabled, and your income is too high to qualify for free Medi-Cal, Medi-Cal's Working Disabled Program may allow you to get Medi-Cal. Note: Medi-Cal's Working Disabled Program used to have a monthly premium. Starting on July 1, 2022, there is no more premium. Learn more about this change.

To qualify, you must

1. Meet the medical requirements of Social Security’s definition of disability. You don't have to meet the income and work requirements.
2. Be a U.S. citizen or meet Supplemental Security Income's non-citizen requirements.
3. 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 pay-stubs or other written verification from an employer to prove that you’re working.
   • Note: You can remain enrolled in the program if you become unemployed for up to 26 weeks.
4. Have countable income less than 250% of the Federal Poverty Level ($3,138 per month for individuals and $4,258 for couples).
   • 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 can make $76,320 a year in gross income and still be eligible for this program.
   • Disability income does not count for the WDP 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.
     • Note: If you got SSDI before you reached retirement age and now your SSDI benefits have been converted to Social Security retirement benefits, they will not be counted as income either.
5. Have countable unearned income less than the appropriate SSI/SSP benefit rate. Again, disability income doesn't count.

If you are single and live on your own, you can use the tool below to help figure out your countable income. Remember not to list any money you get from disability benefits as unearned income. Compare the results to the WDP income limit ($3,138 per month for individuals) to see if you're eligible. If you live with others, you should use DB101's Benefits and Work Estimator instead, since the calculation requires more information about their income.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Impairment Related Work Expenses (IRWEs)	$
Your Monthly Countable Income

For more information Medi-Cal's Working Disabled Program, contact your local county social services agency.

It is important to remember that these are just some 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 at your local county social services agency.