California's Medi-Cal Program, explained.Updated May 26, 2017
Medi-Cal provides health care coverage and services for California residents that meet the eligibility requirements for one of the Medi-Cal programs. Medi-Cal programs cover a wide range of people based on age, disability, income, citizenship, and medical needs. Medi-Cal is funded by both the federal and state government. It is run through the state, and the individual counties handle the eligibility approval process. Under Medi-Cal there are programs funded by the federal government and others funded completely by the state.
Although overall Medi-Cal is for low-income individuals and families, income is not the only factor considered. There are multiple programs to cover children and pregnant women as well as the elderly. There are also special programs to cover those with dialysis needs, tuberculosis, breast and cervical cancer. Medi-Cal provides emergency and prenatal services for those without satisfactory citizenship status.
There are several enrollment options that work to make it as easy as possible for people to apply for Medi-Cal. These include automatic enrollment, presumptive enrollment, accelerated enrollment, and express late eligibility. You can apply online, through the mail, or in person. Applications, information, and help can be found through the county Medi-Cal offices.
Medi-Cal benefits include:
- Medi-Cal for ambulatory patient services
- Medi-Cal for prescription drug coverage
- Medi-Cal for emergency services
- Medi-Cal for rehabilitation services and devices
- Medi-Cal for hospitalization
- Medi-Cal for lab services
- Medi-Cal for maternity and newborn care
Medi-Cal also helps residents of California cover medical costs for health services that include:
- preventative medicine
- chronic disease management
- mental health services
- substance abuse services
- pediatric services
- non-emergency medical transportation services
- long term care
Medi-Cal Eligibility Requirements
Medi-Cal eligibility requirements include reviewing your personal situation on all of the Medi-Cal criteria listed here. These requirements include:
- Income – Each program under Medi-Cal has set income limits based on a percentage of the Federal Poverty Level.
- Immigration – most Medi-Cal programs require individuals to have satisfactory immigration status. However, certain programs such as prenatal care and emergency services are available for those without satisfactory immigration status.
- Disability – Those receiving SSI can receive Medi-Cal coverage as well as those not receiving SSI but who are disabled under the definition of disability by the Social Security Administration.
- Property – Each program has property requirements with the exception of children’s percent programs, income disregard program, minor consent services, safe Arms for newborns, and programs for adoption assistance and former foster care children
Apply for Medi-Cal Online
Where can you apply for Medi-Cal California? Can you apply for Medi-Cal online?
There are several enrollment options for Medi-Cal. Eligibility and approval are determined through the county Medi-Cal offices. Eligibility can take up to 45 days to determine; 90 days to determine eligibility for disabled individuals.
- You can be automatically enrolled when you are enrolled in SSI or CalWORKs.
- Babies born to mothers on Medi-Cal are automatically eligible.
- You can apply in person at a county office, hospital, or clinic.
- You can get immediate coverage while ongoing determination is being decided under certain programs.
- Families enrolled in food stamps or free school lunches can be automatically considered for Medi-Cal.
- When being transitioned off cash assistance programs, you can obtain Medi-Cal coverage.
What are the Medi-Cal Income Guidelines for 2017?
Medi-Cal income guidelines for 2017 were set in early 2016 and run through March 31, 2017. These Medi-Cal for families income guidelines for 2017 consider your family size and your gross income per month in the household, or "monthly gross household income". This chart outlines the income guidelines as set by the state.
Medi-Cal Program Categories
There are several program categories that you can obtain coverage or services under depending on your eligibility. Each of these programs also have subprograms.
- Cash-Related Programs
- Section 1931(b), Medi-Cal for Families
- Children’s Programs
- Income Disregard Program – 200% Program
- 133% Program
- 100% Program
- Minor Consent Program
- Pregnancy-Related Programs
- Income Disregard Program – 200% Program
- Postpartum Program
- Presumptive Eligibility Program
- Senior and Disabled Programs
- Aged/Disabled Federal Poverty Level Program
- Long-term Care Program
- 250% Working Disabled Program
- In-Home Supportive Services (IHSS) Program
- Personal Care Services Program
- IHSS Independence Plus Waiver
- IHSS Residual Program
- Medicare Savings Programs
- Qualified Medicare Beneficiary Program
- Specific low-income Medicare Beneficiary Program
- Qualifying Individual Program
- Qualified Disabled Working Individual Program
- Medically Needy Programs
- Medically Indigent Program
- Transitional Coverage Programs
- Other Medi-Cal Programs
- Breast and Cervical Cancer Treatment Program
- Family Planning, Access, Care, and Treatment
- Dialysis Program
- Tuberculosis Program
- Total Parenteral Nutrition Program
Medi-Cal Eligibility for Californians
Medi-Cal is the California’s Medical Assistance Program that provides health care coverage and services for low-income individuals and families. Medi-Cal covers families, seniors, persons with disabilities, children in foster care, pregnant women, and non –parent adults whose incomes fall below 138% of the federal poverty level (FPL). There are multiple categories and programs under Medi-Cal that cover specific groups or people or medical services.
Medi-Cal is run and administered through the California Department of HealthCare Services and the federal Centers of Medicare and Medicaid Services. The program is funded jointly by the state and the federal Medicaid program. Many of the services offered through Medi-Cal are provided at the local level by the counties through California. Approximately 12.5 million Californians are enrolled in Medi-Cal, which represents approximately 34% of the state population.
California administers Medi-Cal according to federal regulations dictating delivery and quality of service, funding, and eligibility standards. It is overseen by the California Department of Health Services (CDHS) and the Centers for Medicare and Medicaid Services (CMS). Some programs such as the Refugee Medical Assistance program are funded completely by the federal government while others, such as nursing home and prenatal care for individuals without satisfactory immigration status are funded completely by the state.
Although most are eligibility based on medical need or income that is not always enough. Unfortunately, people between the ages of 21 and 65, who are not parents, not pregnant, not blind or disabled, or who do not have one of the qualified medical conditions listed above will not qualify for Medi-Cal. For these people, if your income is low enough, you may qualify for indigent health care services provided through your County.
What are the Different Benefits Categories for Medi-Cal?
Medi-Cal Benefits are broken down into 14 categories. Medi-Cal benefits are a comprehensive set of health benefits that may be utilized when necessary. Beneficiaries may receive free coverage, partial pay coverage, or coverage for specific services. Depending on your medical needs, coverage may be short term or ongoing.
Ambulatory Patient Services
- Physician services
- Hospital outpatient services
- Outpatient clinic services
- Allergy care
- Treatment therapies including chemotherapy and radiation
- Up to 100-day supply of prescriptions
- Coverage of at least one drug from each prescription category and class
- All services needed to treat a medical emergency
- Emergency dental services
Rehabilitation Services and Devices
- Physical therapy
- Heating aids
- Speech therapy
- Medical equipment
- Occupational therapy
- Medical supplies
- Prostheses and orthotics
- 90-day skilled nursing facilities
- Home health aids
- Cardiac rehabilitation
- Pulmonary rehabilitation
- Inpatient hospital services
- Surgical services including bariatric and reconstructive
- Organ and tissue transplants
- Outpatient lab services
- Advanced imaging services when medically needed
Maternity and Newborn Care
- Prenatal care
- Delivery and postpartum care
- Nurse midwife services
- Breastfeeding help and education
Preventative Medicine and Chronic Disease Management
- Smoking Cessation
- Family Planning
- Preventative care for women recommended by the Institute of Medicine
- HRSA’s Bright Futures Recommendations
- U.S. Preventative Services Task Force A & B Recommended Preventative Services
Mental Health & Substance Use Disorder
- Outpatient mental health services
- Outpatient specialty services
- Inpatient specialty services
- Outpatient substance use disorder services
- Residential treatment services
- Voluntary inpatient detoxification
- Early and periodic screening, diagnoses, and treatment
- Routine dental exams
- Fluoride treatments
- Anterior root canals (front teeth)
- Prefabricated crowns
- Emergency dental services
- Dental implants and implant-retained prostheses
- EPSDT and pregnant women benefit from extended benefits
- 1 routine eye exam every 24-mounth period
- Patients under 21 and nursing home residents are eligible for coverage of eyeglasses
- EPSDT and pregnant women benefit from extended benefits
Non-Emergency Medical Transportation Services
- When public or private transportation is not available, and medical care is needed, ambulance or van will be provided.
Long Term Services
- Skilled nursing facility (91+ days)
- Personal care services
- Self-directed personal assistance
- Community first choice option
- Home and community based care
How Medi-Cal Works
Income: includes wages, interest, alimony, and cash assistance. Income should be defined as earned income such as wages or unearned income such as alimony.
Questions you may be asked regarding your income:
- Is it earned or unearned?
- Does it fall under income exception? (Ex: student educational loans are exempt)
- Is it the parent’s income or a child’s income?
- Is the income earner disabled?
- Is the income received weekly, bi-weekly, monthly, quarterly, or annually?
- Is the income allocated to more than one person?
Federal Poverty Level (FPL): The FPL is issued by the Department of Health and Human Services each year. It is used to determine financial eligibility for a wide range of federal and state funded benefit programs. The FPL is the annual income that the federal government has determined to be the poverty level. In addition to general eligibility, the FPL may also be used to determine the level of shared cost for programs outside the free coverage program.
There are several categories of eligibility that you may fit into. Generally speaking, Medi-Cal is for low-income individuals and families that cannot afford health care. However, there are a number of factors that go into determining eligibility.
Those that are eligible:
- People that are categorized as aged, blind, or disabled according to the Social Security Administration guidelines
- Low income families with children
- Children or pregnant women regardless of deprivation or property
- People with specific health care concerns. Those concerns are:
- Need for dialysis
- Total parenteral nutrition services
- Breast cancer treatment
- Cervical cancer treatments
- Services for children
- Those in nursing home facilities
Some people are eligible based on their eligibility for other programs. For example, those that have been approved for CalWORKs or SSI are automatically eligible for Medi-Cal.
Medi-Cal was established in 1965 to provide health care benefits to California residents on already receiving welfare. Since then, the categories of people eligible for health care benefits under Medi-Cal is broadened significantly. The Medi-Cal program has been referred to as a “patchwork” of programs due to the number of categories that have been added. There are many eligibility categories that you may fall into. In most cases, eligibility is based on income, property, and household composition. However, each factor is complex and may vary based on which eligibility category you fall into.
Medi-Cal for Immigrants
Can immigrants qualify for Medi-Cal? In order to be eligible for all Medi-Cal services, an individual must be categorized as having “satisfactory immigration status.” This may include citizens, lawful permanent residents and immigrants that fall under Permanent Resident under Color of Law” (PRUCOL).
Undocumented immigrants and immigrant groups that do not qualify as having satisfactory immigration status may qualify for limited health coverage under Medi-Cal. Limited coverage includes emergency services, pregnancy services, dialysis, and nursing homes.
In order to be eligible for the full range of services, the individual must meet Federal Medicaid law requirements for a “qualified alien.”
The following groups are also eligible for Medicaid.
- Qualified non-citizens who entered the US prior to August 1996
- Qualified immigrants who have finished the five-year waiting period
- Qualified immigrants who are exempt from the five-year waiting period. This category includes refugees, trafficking victims, veteran families, and Asylees.
A qualified non-citizen includes lawful present residents or green card holders, those entering the country from Cuba or Haiti, Battered spouses and children, victims of human trafficking, refugees, and the spouses and children of active military or veterans. Many of the qualified non-citizen groups are also exempt from the five-year waiting period.
Lawfully present residents includes those with Humanitarian status, valid non-immigrant visa holders, those whose legal status was conferred by the following laws: temporary resident status, LIFE Act, Family Unity Individuals, and lawful residents in American Samoa and the Northern Mariana Islands.
States are allowed to extend services funded completely by the state to immigrant groups not qualified by federal standards. However, immigrants need to be aware that depending on their situation, accepting public aid may negatively impact their immigration status.
The Department of Homeland Security is allowed to refuse an individual’s entry or re-entry into the U.S., or prevent an individual from becoming a permanent U.S. resident if they believe the individual is likely to become a “public charge” or someone that will be dependent on public benefits.
Immigrants without a green card and legal permeant residents are protected if they use Medi-Cal and Healthy Families, prenatal care, low-cost clinics and health centers. Those immigrant groups can utilize these programs without fear of being seen as a potential public charge.
In order to be categorized as disabled for Medi-Cal eligibility, you need to meet the Social Security Administration’s definition of disability. The Social Security Administration defines disability as someone who is unable to engage in substantial gainful activity (SGA) due to a medically-determined physical or mental impairment that (1) is expected to result in death, or (2) has lasted or is expected to last longer than 12 continuous months.
Those asserting a disability other than blindness under the Aged/Disabled or Medically Needy Programs have to meet the Social Security Administration’s criteria for being unable to engage in “substantial gainful activity” (SGA). If your work is considered SGA, you may be disqualified. However, if your work is considered SGA, but you still meet the Social Security Administration’s definition of disabled, you may be eligible under the 250% Working Disabled Program.
Federal Poverty Level Eligibility for Medi-Cal
Medi-Cal programs offer multiple levels. Depending on income, you may qualify for Medi-Cal that is free to you, or you may qualify for Medi-Cal that is requires you to share in the cost. This means you would be required to pay for a portion of your medical services.
In determining income eligibility for Medi-Cal, your monthly income will be considered. The table below shows the FPL by family size.
Property Eligibility and Medi-Cal
Property is defined as the things you own such as a car, house, and bank account. Property is considered when determining Medi-Cal eligibility. Different Medi-Cal programs have different property limits that can exclude you from eligibility. The home the family lives in is not counted towards the property limit.
The number of vehicles is counted differently based on the program. In some programs, they count the number of vehicles regardless of value, while in other programs they take into consideration the equity value and fair market value of the vehicle.
A handful of Medi-Cal programs do not consider property when determining eligibility. They are:
- Children’s Percent Program
- Income Disregard Program
- Minor Consent Services
- Safe Arms for Newborns
- Programs for adoption assistance and former foster care children
The 250% Working Disabled Program exempts IRAs and 401(k) accounts from property counts.
Estate Recovery and Medi-Cal
If a beneficiary dies and still owes money for Medi-Cal services that were provided, the amount owed can be recovered from the beneficiary’s estate. The exception to this is that they will not put a lien on the beneficiary’s house if a living spouse or dependent children still live in the home. Survivors can submit a hardship waiver to try and avoid estate recovery.
Medi-Cal Application Process and Redetermination Process
Medi-Cal eligibility is determined at the county level, so the determination process may vary from one county to another. Each county has up to 45 days to determine eligibility for non-disabled applicants, and up to 90 days to determine eligibility for disabled applicants. Express applications are available to children, pregnant women, and patients diagnosed with breast cancer or cervical cancer.
Here are multiple enrollment methods depending on your circumstances
- Automatic Enrollment. When you are enrolled in SSI or CalWORKs, you are automatically enrolled in Medi-Cal.
- Deemed Eligibility for infants. Babies born to a mother that is on Medi-Cal and will be living with their mother in California are automatically eligible for Medi-Cal for the first year.
- Mail-in Medi-Cal Only Application. The Medi-Cal only application or MC 210, can be printed out, completed, and mailed to the county welfare department.
- Medi-Cal/Healthy Families Program Mail-In Application. When applying for Medi-Cal and Healthy Families Program jointly, you can use a shortened mail-in form. You can also apply for these programs jointly online.
- In Person. You can apply in person at your county Medi-Cal office or at a hospital or clinic that has an eligibility worker on staff.
- Presumptive Eligibility. This is immediate short term Medi-Cal coverage while ongoing eligibility is determined.
- Accelerated Enrollment. This enrollment method is for children who apply under the joint Medi-Cal/Healthy Families Program mail-in application, and women who are likely to meet the eligibility requirements for the federal Breast and Cervical Cancer Treatment Program.
- CHDP Gateway Enrollment. The Child Health and Disability Prevention (CHDP) Program can provide up to two months of full coverage for children applying for Medi-Cal or Healthy Families until eligibility it determined.
- Express Lane Eligibility. This allows families already receiving food stamps or free school lunches to be enrolled in Medi-Cal as well.
- Ex Parte Redetermination. This assures that all those receiving Medi-Cal benefits are reevaluated prior to the benefits ending.
County Medi-Cal Offices and Contact Information: Where can I find my Medi-Cal login? What is the Medi-Cal phone number?
Medi-Cal eligibility is determined through the county Medi-Cal office for the county you reside in. A Medi-Cal login is obtained by first reviewing the applications and information that can be obtained through these offices or through the county office websites. County Medi-Cal offices also have staff on hand to help you determine what programs you may be eligible for and to help you through the process. The table below provides contact information for all the county Medi-Cal offices.
|County Name||County Address / Phone / Website|
|Alameda County||Social Services Agency|
8477 Enterprise Way
Oakland, CA 94621
1 (888) 999-4772 Toll Free
|Alpine County||Department of Social Services|
75A Diamond Valley Road
Markleeville, CA 96120
(530) 694-2235 ext. 231
|Amador County||Department of Social Services|
10877 Conductor Blvd
Sutter Creek, CA 95685
|Butte County||Department of Employment and Social Services|
78 Table Mountain Blvd.
Oroville, CA 95965
1 (877) 410-8803
|Calaveras County||Calaveras Works and Human Services|
509 East Saint Charles Street
San Andreas, CA 95249-9701
After Oct 1: (209) 754-6644 – Dedicated to Medi-Cal Inquiries and Applications
|Colusa County||Department of Social Services|
251 East Webster Street
Colusa, CA 95932
|Contra Costa County||Employment and Human Services Department|
Workforce Services Bureau
1 (800) 709-8348 Medi-Cal
1 (800) 300-1506 Contra Costa County Covered California Call Center (7 Cs)
|Del Norte County||Department of Health and Human Services|
880 Northcrest Drive
Crescent City, CA 95531-3485
|El Dorado County||Department of Social Services|
3057 Briw Road
Placerville, CA 95667-1637
(530) 642-7300 Placerville Office
(530) 573-3200 South Lake Tahoe Office
|Fresno County||Department of Human Services|
1 (855) 832-8082 Call Center, Toll Free
(559) 600-1377 Automated Assistance
|Glenn County||Health & Human Services Agency|
P.O. Box 611, 420 East Laurel Street,
Willows, CA 95988-0611
|Humboldt County||Department of Social Services|
929 Koster Street
Eureka, CA 95501
1 (877) 410-8809
|Imperial County||Department of Social Services|
2995 South Fourth Street, Suite 105,
El Centro, CA 92243
|Inyo County||Department of Social Services|
920 N Main St.
Bishop, CA, 93514
|Kern County||Department of Human Services|
100 E. California Avenue,
Bakersfield, CA 93307
|Kings County||Human Services Agency|
1400 W. Lacey Blvd., Building #8
Hanford, CA 93230
1 (877) 410-8813 Toll Free
|Lake County||Department of Social Services|
15975 Anderson Ranch Parkway,
P.O. Box 9000
Lower Lake, CA 95457-9000
|Lassen County||Lassen WORKS|
Roosevelt Annex, 720 Richmond Road
Susanville, CA 96130
|Los Angeles County||Department of Public Social Services|
1 (877) 597-4777 Toll Free
1 (66) 613-3777 Customer Service Center
|Madera County||Department of Social Services|
720 E. Yosemite Avenue
Madera, CA 93639-0569
|Marin County||Dept Health & Human Services (Public Assistance)|
120 N. Redwood Dr -West Wing
San Rafael, CA 94903
|Mariposa County||Department of Human Services|
5362 Lemee Lane
PO Box 99
Mariposa, CA 95338
1 (800) 549-6741 Toll Free
|Mendocino County||Fort Bragg Office:|
764 S. Franklin Street,
Fort Bragg, CA 95482
737 South State Street, P.O. Box 8508
Ukiah, CA 95482
|Merced County||Human Services Agency|
2115 West Wardrobe Avenue,
Merced, CA 95340
|Modoc County||Department of Social Services|
120 North Main Street,
Alturas , CA 96101
|Mono County||South County Office:|
452 Old Mammoth Rd, 3rd Floor, P.O. Box 2969
Mammoth Lakes, CA 93546
North County Office:
85 Emigrant Street, P.O. Box 576
Bridgeport, CA 93517
|Monterey County||Department of Social and Employment Services|
1000 South Main Street- Suite 216
Salinas, CA 93901
1-877-410-8823 Toll Free
|Napa County||Department of Health and Human Services|
2261 Elm Street
Napa, CA 94559
1 (800) 464-4214 Toll Free
|Nevada County||Human Services Agency|
950 Maidu Avenue, P.O. Box 1210
Nevada City, CA 95959
1 (888) 809-1340 Toll Free
|Orange County||Social Services Agency|
(Call for the nearest district office)
1 (800) 281-9799 Existing Clients
(949) 389-8456 24-Hour Automated Assistance
(714) 541-4895 24-Hour Automated Assistance
To apply for benefits:
1 (855) 478-5386
|Placer County||Health and Human Services|
11542 B. Ave
Auburn, CA 95603
1000 Sunset Blvd. Suite 220
Rocklin, CA 95765
North Tahoe Office:
5225 North Lake Blvd.
Carnelian Bay, CA 96140
1 (888) 385-5160 Toll Free
(916) 784-6000 If you are outside the County
|Plumas County||Dept of Social Services|
270 County Hospital Rd, Suite 207
Quincy, CA 95971
|Riverside County||Department of Public Social Services|
(Call for the nearest district office
1 (800) 274-2050 Toll Free
|Sacramento County||Sacramento County Department of Human Assistance|
1725 28th Street
|San Benito County||Human Services Agency|
1111 San Felipe Rd, Ste 206
Hollister, CA 95023-3801
|San Bernardino County||Human Services System|
Transitional Assistance Department
1 (877) 410-8829
|San Diego County||Dept of Health & Human Srvs Agency|
1 (866) 262-9881
|City & County of San Francisco||San Francisco Human Services Agency|
SF Benefits Net
1440 Harrison St
San Francisco, CA 94120
1 (855) 355-5757 Toll Free
|San Joaquin County||Human Services Agency|
333 E. Washington Street
Stockton, CA 95202
|San Luis Obispo County||Department of Social Services|
3433 S. Higuera Street
San Luis Obispo, CA 93403
|San Mateo County||Human Services Agency|
400 Harbor Boulevard, Building "B"
Belmont, CA 94002
1 (800) 223-8383 Toll Free
|Santa Barbara County||Department of Social Services|
234 Camino Del Remedio
Santa Barbara, CA 93110
1 (866) 404-4007 Toll Free
|Santa Clara County||Social Services Agency|
Assistance Application Center
1867 Senter Road
San Jose, CA 95112
1 (877) 962-3633 Automated
|Santa Cruz County||Human Services Department|
1020 Emeline Ave.
Santa Cruz, Ca 95060
1 (888) 421-8080
|Shasta County||Health & Human Services Agency|
2460 Breslauer Way, P.O. Box 496005
Redding, CA 96001
1 (877) 652-0731
|Sierra County||Social Services|
202 Front Street, P.O. Box 1019
Loyalton, CA 96118
|Siskiyou County||Human Services|
818 S. Main Street
Yreka, CA 96097
|Solano County||Health and Social Services|
Medi-Cal and County Medical Services Program (CMSP)
Fairfield: (707) 784-8050
Vacaville: (707) 469-4500
Vallejo: (707) 553-5000
|Sonoma County||Human Services Department|
2550 Paulin Drive
P.O. Box 1539
Santa Rosa, CA 95402-1539
1 (877) 699-6868
|Stanislaus County||Community Services Agency|
251 East Hackett Road, P.O. Box 42 95353
Modesto, CA 95355
1 (877) 652-0734
|Sutter County||Department of Human Services|
Welfare Social Services Division
539 Garden Highway, P.O. Box 1535,
Yuba City, CA 95991
|Tehama County||Department of Social Services|
310 South Main Street, P.O. Box 1515,
Red Bluff, CA 96080
|Trinity County||Dept of Health and Human Services|
#51 Industrial Parkway, P.O. Box 1470,
Weaverville, CA 96093-1470
1 (800) 851-5658 Toll Free
|Tulare County||Health & Human Services Agency|
1 (800) 540-6880 Toll Free
|Tuolumne County||Department of Social Services|
20075 Cedar Road North
Sonora, CA 95370
|Yolo County|| Woodland, CA 95695|
West Sacramento Office
500-A Jefferson Boulevard
West Sacramento, CA 95605
111 East Grant Avenue
Winters, CA 95694
|Yuba County||Health and Human Services Department|
5730 Packard Avenue, Suite 100, P.O. Box 2320
Marysville, CA 95901
Medi-Cal Cash-Related Programs
California residents that have been approved for a federally funded program that provides direct cash assistance are automatically qualified for Medi-Cal. These programs include:
- Supplemental Security Income (SSI)
- Foster Care Assistance
- Adoption Assistance
- Entrant or Refugee Cash Assistance
Section 1931(B), Medi-Cal for Families
Section 1931(b) of the Social Security Act ensures that families with children, who are in financial need will get access to Medi-Cal. This eligibility category combines the eligibility criteria from several other programs including food stamps, AFDC, and CalWORKs. Federal regulations also allowed states to choose to make their financial requirements less restrictive than the federal guidelines in order to cover more families. Under this allowance, California decided to do so. Based on this, Section 1931(b) is separated into two categories:
- Cash-based Section 1931(b). This is the Medi-Cal program for all families receiving CalWORKs money.
- Section 1931(b) Only. This program provides Medi-Cal coverage for all families that would have been eligible for AFDC if that program was still in effect. This program also covers families that are eligible for CalWORKs but choose not to receive cash benefits.
Section 1931(b) category is the only eligibility category that provides coverage to an entire family. If a family is in this program but their income increases enough to make them ineligible, they can be moved to the Transitional Medi-Cal coverage plan.
Medi-Cal Children’s Programs
Children’s programs are intended to ensure that no child in need goes without health coverage. Many of the other Medi-Cal programs also cover children, but these programs specifically address children. Children’s programs account for 4.5% of all Medi-Cal recipients.
This coverage area includes:
- Medi-Cal for Minors
- Medi-Cal for Students
- Medi-Cal for Kids
- Medi-Cal and Child Support
- Medi-Cal and Pregnancy
Of the children’s programs, there are three programs that base eligibility solely on family income, which is based on what percentage of the FPL the family income falls under. For that reason, these are commonly referred to as the percent programs. The percent programs do not take family property into consideration. The majority of the children in these programs have at least one working parent, and the parent’s employer either offers no health coverage at all or no health coverage for dependents.
These programs divide children by family income and age, which can make it difficult for parents with multiple children in different age groups. It is possible that your income is low enough to make some of your children eligible for Medi-Cal but not others.
Income Disregard Program – 200% Program. This particular program is also referred to as the Federal Poverty Level Program for Infants and Pregnant Women. Under this program, children that are one year old or younger with a family income at or below 200% of the FPL receive full Medi-Cal coverage. If the child does not have satisfactory immigration status, he or she will only be eligible for emergency services.
133% Program. This program provides Medi-Cal coverage for children between the ages of one and six as long as their family income is at or below 133% of the FPL. Again, children in this group that do not have satisfactory immigration status will only be covered for emergency services.
100% Program. This program provides Medi-Cal coverage for children between the ages of 6 and 19 as long as their family income is at or below 100% of the FPL. Children without satisfactory immigration status will be covered for emergency services only
Other Children’s Programs
In addition to the percent programs there are three other programs that can be used for health coverage depending on the age and needs of the child.
Minor Consent Program. This program is for those under the age of 21, who are unmarried and still claimed as a dependent on their parent’s tax return. Eligibility is based on the minor’s income and resources, opposed to the parent’s. Additionally, coverage for this program and subsequent services do not require parental consent or notification. Minors have to prove eligibility each month for this program. This program includes coverage of the following services:
- Substance abuse treatment
- Mental health services
- STD treatment
- Sexual assault treatment
- Family planning services
- Pregnancy/prenatal services
Accelerated Enrollment. This program is designed to get children immediately enrolled for health coverage, while their eligibility for ongoing Medi-Cal coverage is determined. Coverage ends at the end of the month during which the child is deemed eligible or ineligible. If deemed eligible, they are moved to the program they are eligible under. Accelerated enrollment has three criteria:
- Complete the joint Medi-Cal/Healthy Families application
- Apply through the Single Point of Entry
- Appear eligible for no-share-of-cost Medi-Cal
National School Lunch Program Express Enrollment. Under this program, children that are eligible for the free meals program at school can be automatically evaluated for Medi-Cal. The children are fully covered until eligibility is determined.
Can I qualify for Medi-Cal if I'm pregnant? Here are Medi-Cal's Pregnancy-Related Programs
There are three pregnancy-related programs that a woman may be eligible under. These programs do not take immigration status into consideration. These programs cover specific pregnancy-related services and coverage is determined on a case-by-case basis. Pregnancy programs account for 1% of all Medi-Cal recipients.
Income Disregard Program – 200% Program. This program is also listed under the children’s programs because coverage can include pregnant and postpartum women. This program waives the property considerations for pregnant women that is used to determine eligibility in other Medi-Cal programs. This program provides pregnancy-related care as determined by the woman’s doctor, family planning services, and postpartum care for 60 days after birth or end of pregnancy. This program is for women whose family income is at or below 200% of the FPL.
Postpartum Program. This program is for women that were covered for their pregnancy through the Medically Indigent Program, which includes a share of costs. The postpartum program will provide coverage without shared cost for at least 60 following the birth or end of pregnancy.
Presumptive Eligibility Program. This is a temporary program used to provide early prenatal care. A woman who is pregnant can be eligible for this program by answering a few income and residency questions and agreeing to later apply for regular Medi-Cal through her county office. A woman can apply for this program through her doctor’s office or health clinic. Medical services covered under the presumptive eligibility program are still covered even if she is later determined to be ineligible. If it is determined she is eligible, she’ll be moved to a regular Medi-Cal program. This program covers all prenatal services, but does not cover delivery, family planning, or optional abortions.
Medi-Cal for Seniors and and Medi-Cal Disabled Programs
The programs available under this category are divided into two categories. There are the general senior and disabled programs and there are programs designed to cover the medical expenses not covered by Medicare.
Aged/Disabled Federal Poverty Level Program. This program provides no cost coverage to seniors and people with disabilities that would be required to share in costs under the Medi-Cal Medically Needy Program. Children with disabilities can also be eligible for this program if they meet the income requirements and Social Security Administration standards for a disability. Individuals who do not have satisfactory immigration status, but would otherwise qualify, may be covered for emergency services only.
Long-Term Care Program (LTC). This program aims to help the elderly, people with disabilities, and people with chronic disabilities. This program covers the costs of medical and nursing facilities or in-home care. In-home care may include personal care, case management, and community-based services. Most long-term care benefits are covered under other programs. This program, however, has different criteria to benefit married couples. When one partner is institutionalized but the other is not, the property requirements are altered to ensure the spouse still living independently can continue to do so financially.
250% Working Disabled Program. This program is specifically for disabled individuals that are still able to work. In order to be eligible for this program, you must have a total income of less than 250% of the FPL. You have to meet the Social Security Administration’s definition of disabled, and you must have less than $2,000 in personal property. The personal property limit does not count retirement plans or other accounts approved by the IRS.
This program allows you to deduct all disability-based income from total income to qualify under the income requirement. This means if you are deceiving cash benefits through SSI that will not be included when determining total income.
In-Home Supportive Services (IHSS) Program. There are three separate programs that fall under this category. Each program is designed to allow the elderly and people with disabilities to stay in their own homes. Although IHSS services are considered part of the Medi-Cal program, being eligible to receive these services does not mean you are automatically eligible for Medi-Cal health coverage.
Personal Care Services Program – this program includes ancillary services as well as protective supervision. In order to qualify for this program, you need to meet eligibility requirements for full scope, federally funded Medi-Cal
IHSS Independence Plus Waiver – Services under this program include personal care, protective supervision, domestic service, and transportation. To qualify for this program, you must be eligible for full scope, federally funded Medi-Cal. In addition to that, individuals have to go through a needs assessment by an IHSS social worker to determine need.
IHSS Residual Program – This is a state/county-funded program that provides domestic services for individuals who are aged, blind, or disabled and do not qualify for the other two IHSS programs.
Medi-Cal and Medicare: Medicare Savings Programs
These programs are available to low-income individuals already receiving Medicare benefits. The programs are intended to help cover medical expenses not covered by Medicare. These programs can be applied for through the county Medi-Cal offices.
Qualified Medicare Beneficiary (QMB) Program. This program is essential a free Medicare supplemental health policy. The program covers out of pocket expenses such as deductibles and a percentage of doctor visits. It can cover premiums for Medicare Part A and Part B. While it does not cover Part D, recipients can get a subsidy to help pay Part D premiums. In order to be eligible, you have to make less than 100% the FPL.
Specified Low-Income Medicare Beneficiary (SLMB) Program. This program covers the premiums for Medicare Part B only. To be eligible, you must make less than 120% of the FPL. You may also qualify for full Medi-Cal coverage.
Qualifying Individual 1 (QI-1) Program. This program covers the Medicare Part B premiums for people that make between 120% and 135% the FPL. Individuals on this program are ineligible for full Medi-Cal coverage.
Qualified Disabled Working Individual (QDWI) Program. This program is intended to cover the premiums for Medicare Part A. To be eligible for this program, you must make less than 200% the FPL and have less than $4000 in countable resources.
Medically Needy (MN) programs
This program is for people that do not qualify for cash assistance programs like SSI or CalWORKs and meet the SSE requirements for age, blindness, or disability. The program can also cover those that would have qualified under the previous criteria for AFDC. You have to fit into one of the following categories:
- 65 or older
- Parents or children who meet the requirements for deprivation
- Caretaker relatives
There are two versions of this program; one that includes shared costs and one that does not include shared cost. Which program you are eligible is dependent on income.
The Medi-Cal Medically Indigent (MI) Program
The MI Program follows the same income requirements as the MN Program, but provides coverage for specific groups of people that may not fall into the demographic requirements of the MN Program. This program provides coverage for the following groups.
- Abandoned babies
- Children receiving foster care assistance
- Children who are eligible for Aid for Adoption of Children
- Pregnant women and individuals under the age of 21 that do not meet the requirements for the Medically Needy Program
- People between the ages of 21 and 65 that live in nursing facilities but are not disabled
- People without satisfactory immigration status that require nursing home care
Medi-Cal Transitional Coverage Programs
Transitional Coverage Programs are for people that are in a state of transition. This may include people transitioning off of CalWORKs or off of SSI. It may also include people that are leaving the foster care program, experience a change in alimony or child support payments that impacts their eligibility, or people that may experience ineligibility for other programs due to a divorce or death of their spouse. Transitional coverage can also be used to cover individuals while they are being determined for eligibility for certain programs such as the pregnancy-related programs.
Other Medi-Cal Programs
There are a handful of Medi-Cal programs available that do not fall under any of the other categories. These are limited scope programs because they cover the medical expenses related to a specific medical need or condition.
Breast and Cervical Cancer Treatment Program (BCCTP). This program covers the medical expenses related to the treatment of breast and cervical cancer. To be eligible for this program, you must be a California residents diagnosed with breast or cervical cancer and make no more than 200% the FPL. Applicants that meet the following requirements may be eligible for no share Medi-Cal coverage.
- Under 65 years of age
- A citizen or individual with satisfactory immigration status
- No creditable health insurance
- Been diagnosed with breast or cervical cancer
- Be in need of treatment
Applicants may be covered through presumptive eligibility while their eligibility status is being determined.
Family Planning, Access, Care, and Treatment (PACT). This program covers a range of family planning services for both men and women with incomes at or below 200% of the FPL. This program provides partial or full coverage for contraception, emergency contraception, pregnancy counseling, Preconception consoling, pregnancy testing, sterilization, STD testing, STD treatment, cancer screening, HIV screening, and hepatitis B immunization.
Dialysis Program. This program covers medical expenses related to kidney dialysis. It is designed for people that are not eligible for SSI or disability-based Med-Cal. Individuals with higher incomes can qualify and pay on a sliding scale based on their income and property.
Tuberculosis (TB) Program. This program is to cover medical expenses for tuberculosis-related services. Having TB does not automatically qualify somewhere for SSI or disability-based Medi-Cal. There are set income and property limits for eligibility.
Total Parenteral Nutrition (TPN) Program. This program covers TPN intravenous feedings. People that require TPN, but still work may not be eligible for disability-based Medi-Cal. This program provides services on a sliding scale based on their income and property.