Medical Benefits: Keeping What You Have Now

It is important to know what type of health care coverage you have so you know how that coverage may change when you go to work. The following are common health care coverage programs for people with disabilities.

Medicare

Medicare is the federal health insurance program for people over age 65 and people with disabilities who are on Social Security Disability Insurance (SSDI):

• If you have received SSDI payments for more than 2 years (24 months) you are probably on Medicare.
• If you’ve been on SSDI for less than 24 months, your Medicare will start when you’ve received payments for 24 months.
• If you were found to be disabled on appeal and got a retroactive, lump sum payment that is equal to 24 months or more of SSDI payments, you will be immediately eligible for Medicare.
• If you are under age 65 and have end stage renal disease or Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) you may be eligible for Medicare.

In any case, you will be notified by mail up to 120 days before you become eligible. Make sure that Social Security always has your most current address and all other contact information.

Medicare Part A — Hospitalization

Medicare Part A pays for hospital stays. If you’re on SSDI, you won’t have to pay a premium for Medicare Part A, but there may be other expenses. For instance, if you’re admitted to the hospital, you may have to pay a $1,156.00 deductible each benefit period before Part A will begin paying your hospital costs. If you’re in the hospital for more than 60 days, you may be charged $289.00 - $578.00 per day or more. However, if you also have Medi-Cal coverage, it will pay the Part A costs for you. Click here for more information on Part A hospitalization costs.

Medicare Part B — Outpatient

Medicare Part B helps pay for the medical care you get when you are not staying in a hospital but when you go to see the doctor. Part B coverage is “voluntary.” You don’t have to enroll when it is first offered but if you don’t, you may have to pay a penalty when you do sign up. If, however, you have creditable coverage you won’t have to pay the penalty.

If you choose to keep your Part B coverage, you may have to pay a monthly premium that will be automatically deducted from your SSDI check. The Part B premium for most people who do pay is $99.90 per month in 2012. You may also have to pay a yearly deductible of $140 and 20% coinsurance.

Medicare recipients who also have Medi-Cal with no Share of Cost do not have to pay a premium for Part B. They, as well as Californians with very low incomes, may qualify for a Medicare Savings Program. Contact the California Department of Health Care Services (DHCS) county office to apply for these programs.

Medicare Part C — Medicare Advantage

Medicare Advantage Plans are offered by private insurers. Their Part C policies are paid for by Medicare but each private plan has its own policies, costs, and covered services. Read and compare the policies thoroughly before deciding whether or not a Medicare Advantage Plan suits your needs best. You can get more information about Part C on the Medicare website.

Medicare Part D — Prescription Drug Coverage

Medicare Part D provides prescription drug coverage from private insurance companies. Some — but not all — Part D participants have to pay a lot of money out-of-pocket for their meds. For instance, some Part D plans charge a $320 yearly deductible. You may also have to pay for 25% of your drug costs until your total drug costs equal $2,930. At that point, you will have to pay for all of your drugs until the total equals $6,657.50. Once this is reached, Medicare D will pay 95% of all medication costs until the end of the year.

Note: Some of these costs are beginning to be reduced because of the Affordable Care Act. If you pay out of pocket deductibles and coinsurance payments, when you reach the Medicare Part D coverage gap, known as the “donut hole,” you get a discount on your prescription drugs. In 2020, these out-of-pocket expenses will no longer exist.

If you’re enrolled in Medicare Parts A and B, as well as in a no Share of Cost category of Medi-Cal, then you will automatically qualify for the Medicare Part D Low Income Subsidy (LIS). With the Low Income Subsidy, all you have to pay for your medications is a copayment of to $6.50 per prescription.

There are many different plans for Part D that charge different premiums and provide different coverage. You should pick a plan that works best for you. You can compare plans at the Medicare website. Click here for information and instructions about comparing the plans that will work best.

If you have questions, talk to your pharmacist about which plan(s) would best suit your needs. You can also talk to a HICAP Medicare counselor at 1-800-434-0222. They can help you compare plans and provide the best possible options for you to choose from.

Medicare and Work —Extended Medicare

When you work and get SSDI you keep your Medicare — plain and simple. In fact, you can keep your Medicare for at least 8 ½ years after you return to work. (The 8 ½ years includes your 9-month Trial Work Period.) After your Trial Work Period, you will get at least 7 years and 9 months of continued Medicare coverage, as long as your disabling condition still meets Social Security’s rules.

Medi-Cal

Medi-Cal is California’s Medicaid Program. It is a federal and state-funded health care program that pays medical expenses for people who have low incomes and are disabled, elderly, young, or pregnant.

Medi-Cal is overseen by the State of California and administered by each of its 58 counties. There are over 200 categories of Medi-Cal. You can see these different categories and their Aid Codes by clicking here.

Many people with disabilities who have Medicare also qualify for Medi-Cal.

Medi-Cal covers most services that Medicare doesn’t. These include extended In Home Supportive Services (IHSS) and Long-Term Care (LTC), as well as both physical and mental health services. Medi-Cal may also help with Medicare premiums, coinsurance, and deductibles.

If you are on Medi-Cal with No Share of Cost, you are automatically eligible for the Medicare Part D Prescription Drug Plan’s Low Income Subsidy (LIS). If you are on Aged, Blind, Disabled, & Medically Needy Medi-Cal (also known as Share of Cost Medi-Cal), once you have met your Share of Cost, you will automatically be eligible for the subsidy. It begins in the month after the month you meet your Share of Cost and lasts for the rest of that year (or through the following year if you meet your Share of Cost after a certain point in the year). Those eligible for the LIS will still have to pay copayments for each prescription but they won’t be charged deductibles or coinsurance.

Medicare will not charge for Part D premiums that are at or below California’s Benchmark Plan. The premium average is $32.35 per month.

Medi-Cal and Disability

The 5 categories of Medi-Cal that relate closely to the disabled are:

1. 1619(a) – SSI-linked Medi-Cal – No Share of Cost
2. 1619(b) – SSI-linked Medi-Cal – No Share of Cost
3. Aged, Disabled Federal Poverty Level – No Share of Cost
4. Aged, Blind, Disabled, & Medically Needy – Share of Cost
5. The Medi-Cal Working Disabled Program – Premium

The rest of this page discusses these categories.

1619(a)

Anyone receiving even $1 of Supplemental Security Income (SSI) is eligible for No Share of Cost Medi-Cal. It is part of SSI. If you’ve got SSI, you’ve got Medi-Cal and you shouldn’t ever have to pay anything out of pocket as long as Medi-Cal covers it. There may be a few exceptions — some drugs or some medical procedures are not covered by Medi-Cal — but those instances are rare. Let’s just say if you have SSI, you have Medi-Cal.

1619(b)

Californians on SSI who earn so much income (over twice their SSI payment) that they no longer get an SSI cash benefit will continue to keep their Medi-Cal because of the 1619(b) program. 1619(b) is a provision of SSI that protects your health care coverage when you go to work. 1619(b) does not charge a premium.

1619(b) protects your health care coverage up a yearly gross income of $36,423. Your assets, however, still cannot be more than the SSI asset limit ($2,000 for an individual, $3,000 for a family of two).

To qualify for 1619(b) you must:

• Have been eligible for an SSI cash payment for at least one month
• Not be getting an SSI payment because you earn too much
• Still be disabled or blind
• Not have more than the SSI asset limit ($2,000 for individuals, $3,000 for a couple)
• Need to be able to work
• Not make enough money to pay for the services you get with benefits
• Respond to all Social Security requests for information

Click here for more information about 1619(b).

Aged, Disabled, Federal Poverty Level Medi-Cal

Medi-Cal is based on your income. Those who are disabled with incomes less than $1,138 per month but greater than the $854.40 SSI maximum are eligible. Assets must be less than $2,000 for an individual. Anything more than that disqualifies the applicant from receiving Medi-Cal.

Aged, Blind, Disabled, & Medically Needy with Share of Cost

A Share of Cost is an out-of-pocket expense. A person with a disability may have Medi-Cal without a Share of Cost. It depends upon which category of Medi-Cal they have. Each category is determined by factors such as disability income, household income, marital status, and number of children under the age of 18 living at home, among others.

Here are some examples:

• A person who gets SSI has Medi-Cal with No Share of Cost.
• A person whose monthly income is greater than the maximum SSI payment but less than $1,138 will have Medi-Cal with No Share of Cost.
• A person with an income greater than $1,138 per month will likely have Medi-Cal with a Share of Cost.
• A person enrolled in the Medi-Cal Working Disabled Program will not have a Share of Cost but will pay a premium each month.

What is a Share of Cost?

A person with a disability on Medi-Cal with a Share of Cost must pay all but $620 of their monthly income to their health care providers before they have access to Medi-Cal for the rest of the month.

The $620 is made up of the following:

It doesn’t matter how much money you get each month. All but $620 of it must be used to pay charges from your health care providers before “free” Medi-Cal becomes available to you for the rest of that month.

Share of Cost is very expensive. Not many people can live on $620 per month. So, if you’re on Medi-Cal you will want to avoid a Share of Cost. There are also some legitimate deductions that can lower your total countable income below the $1,138 income limit for a No Share of Cost plan. Contact your Medi-Cal eligibility worker with questions.

Medi-Cal Working Disabled Program

Medi-Cal’s Working Disabled Program provides any disabled person who earns income to buy into to full-scope, no Share of Cost health care coverage for as little as $20 per month.

People who work earn income. The type of job doesn’t matter. The number of hours worked doesn’t matter. The amount of earned income at the end of the month does matter because it determines the amount of the premium to be paid.

This chart shows Medi-Cal Working Disabled Program premium payments based upon earned income per month.

Medi-Cal Working Disabled Program Premium Payments

Countable Earned Income Range	Premium for Eligible Single Person	Premium for Eligible Couple
$1–$600	$20	$30
$601–$700	$25	$40
$701–$900	$50	$75
$901–$1,100	$75	$100
$1,101–$1,300	$100	$150
$1,301–$1,500	$125	$200
$1,501–$1,700	$150	$225
$1,701–$1,900	$175	$275
$1,901–$2,100	$200	$300
$2,101–$2,269	$250	$375
$2,270–$3,065	N/A	$375

In addition to eliminating the Share of Cost money that you have to pay out of your pocket, the Medi-Cal Working Disabled Program has several other features that make it special and very beneficial to those who have it.

The most significant of these special features is that the Working Disabled Program allows you to save any amount in a retirement fund like an IRA or a 401k or 403b. You can begin to save for your future.

You can read the FAQs on the Working Disabled Program on the DB101 article on Medi-Cal.

For more information on the Working Disabled Program and directions on how to enroll contact the county social services agency.

Medi-Cal and Private Health Coverage

Two more myths:

• You can’t have Medi-Cal or Medicare if you have private health care coverage. This is incorrect.
• You can’t have private health care coverage if you have Medi-Cal or Medicare. This is incorrect.

Sometimes it is better to be covered by as many programs as possible, including Medi-Cal, Medicare, private health coverage and employer-sponsored health care because there may be services you need that one covers but the other does not. Also, if you have Medi-Cal and private or employer-sponsored coverage, Medi-Cal may pay the premium, coinsurance, and deductibles for your policy if it is cost-effective. This is the Medi-Cal/HIPP program and you can find out more about it in the DB101 article on Medi-Cal.