Glossary: Medi-Cal

A rule that lets people who stop getting Supplemental Security Income (SSI) benefits due to work income keep their Medi-Cal health coverage while earning up to $58,638 per year. 1619(b) also makes it easier to get SSI benefits started up again if your countable income goes below SSI's income limit. For 1619(b), you must continue to meet other SSI eligibility rules, such as the resource limit.

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.

A low cost health coverage program for uninsured, middle-income pregnant women and their infants.

A program that pays for some or all of the costs associated with HIV/AIDS medications. ADAP only covers Federal Drug Administration (FDA) approved medications on its formulary (list of covered prescriptions).

A Medi-Cal eligibility category that gives free Medi-Cal to people who are disabled or at least 65 years old and who meet income, asset, and medical requirements.

The $20 of earned or unearned income that is not included when the Medi-Cal countable income calculation is used.

The person who is getting a benefit.

A trained expert who can help you understand and apply for benefit programs. Their goal is to help you develop a plan for your future and organize your financial life to run as smoothly as possible.

  • For questions about work and your Social Security benefits, use Social Security's "Find Help" tool to locate a WIPA project near you. You can also call the Ticket to Work Help Line at 1-866-968-7842 / 1-866-833-2967 (TTY/TDD). The Department of Rehabilitation (DOR) also has Work Incentives Planners (WIPs).
  • If you need assistance with your Medicare, the Health Insurance Counseling & Advocacy Program can help. HICAP provides free information and counseling to people with Medicare. You can call HICAP at 1-800-434-0222 or visit the HICAP website.
  • If you need assistance with Medi-Cal and have a disability, you can contact Disability Rights California at 1-800-776-5746 or visit their website. You may also be able to get help with Medi-Cal from a local legal aid organization. The Health Consumer Alliance website has a lot of useful information about Medi-Cal, including a web page that can direct you to a local legal organization for assistance.
  • If you have questions or need assistance with a program or benefit not listed here, contact an Independent Living Center. Independent Living Centers provide peer support and information on a wide range of topics for people with disabilities.

A Medi-Cal program that pays for costs associated with breast and cervical cancers.

The formula used to determine income and to consider eligibility for SSI-Linked, Medically Needy, and Aged and Disabled Medi-Cal programs.

Step 1: If you have unearned income (for example, an SSDI benefit), subtract a $20 "General Income Exclusion" from it to calculate your countable unearned income. If you do not have unearned income, this exclusion is applied to any earned income.

Step 2: If you have earned income (for example, wages), subtract a $65 "Earned Income Exclusion" from it (along with the remainder of the $20 "General Income Exclusion" that you have not applied to Unearned Income), along with any Impairment Related Work Expenses, and divide the resulting figure by two to find your countable earned income. If you have Blind Work Expenses, subtract them after you divide by two.

Step 3: Add your countable unearned income to your countable earned income to find your total countable income.

Different Medi-Cal programs may include more deductions or exclude certain types of income. See the program descriptions for details.

Rules used by Social Security and Medi-Cal that determine an individual’s eligibility when living with a non-disabled spouse. If the individual is a minor, deeming rules apply to the parents.

The inability to engage in any Substantial Gainful Activity (SGA) due to any medically determinable physical or mental impairment which can be expected to result in death or last for a continuous period of at least 12 months.

A person must not only be unable to do his/her previous work but cannot, considering age, education, and work experience, engage in any other kind of SGA which exists in the national economy. It doesn't matter whether such work exists in the immediate area, or whether a specific job vacancy exists, or whether the worker would be hired if he/she applied for work. The worker’s impairment(s) must be the primary reason for his/her inability to engage in SGA.

An agency ruling that your disability meets the standards set by the Social Security Administration's definition of disability. Your disability must be reviewed and determined to match the SSA definition before you can get certain public benefits. If you're on SSI, SSDI, or any California disability benefits program, you've already been determined disabled.

A term used to describe individuals eligible for both Medicare and Medi-Cal.

Salaries, wages, tips, professional fees, and other amounts you receive as pay for physical or mental work you perform. This can include things you get in exchange for work instead of wages, such as food, shelter, or other items. Funds received from any other source are not included. (Contrast: unearned income.)

Income received from work that is disregarded in the countable income calculation. This calculation evaluates an individual’s financial eligibility for Aged and Disabled Federal Poverty Level (ADFPL), Breast and Cervical Cancer Treatment Program (BCCTP), In-Home Supportive Services (IHSS), Medically Needy (MN) and Working Disabled Program (WDP) Medi-Cal.

A way to qualify for Medi-Cal health coverage. There are several different ways to qualify, each with specific requirements. An individual may be eligible for more than one category.

Either a:

Monthly and annual income amounts used to determine financial eligibility for state and federal benefit programs.

Each year, the U.S. Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines (FPG) in the Federal Register. The current FPG for one person is $15,060 per year; for two people, it's $20,440. Add $5,380 for each additional person.

Some agencies refer to these guidelines as the "Federal Poverty Level (FPL)" or "Federal Poverty Line (FPL)."

Note: Different state and federal programs adopt the new Federal Poverty Guidelines on different dates each year.

Complete medical services offered to beneficiaries such as:

  • Inpatient hospital services (tests, surgeries, procedures)
  • Outpatient hospital services
  • Physician services
  • Medical and surgical dental services
  • Nursing services
  • Home health care
  • Family planning and supplies
  • Rural health clinic and ambulatory services
  • Laboratory and x-ray services
  • Pediatric and family nurse practitioner services
  • Nurse-midwife services
  • Early and periodic screening
  • Diagnosis and treatment (EPSDT) services
  • Prenatal and delivery services
  • Ambulatory services for individuals in an institution
  • Home health services
  • Clinic services
  • Nursing facility services (under 21 years old)
  • Intermediate care facility/developmentally disabled services
  • Optometrist services and eyeglasses
  • Prescribed medication
  • TB-related services for TB infected persons
  • Prosthetic devices
  • Dental services
  • Preventative and rehabilitative services
  • Case management
  • Private duty nursing
  • Home respiratory care services
  • Personal care services
  • Home and community based waivers
  • Medical equipment and appliances
  • Diagnostic screening

The $20 of earned or unearned income that is not considered when determining the amount for the Supplemental Security Income (SSI) benefit.

Your earned income (before taxes and other deductions are made) plus your unearned income.

A case law that allows a Medi-Cal recipient to use prior unpaid medical expenses to meet their monthly share of cost.

A specified amount of earned or unearned income that is excluded from consideration in the financial eligibility requirements for a Medi-Cal program.

Being responsible for medical expenses before Medi-Cal coverage begins.

A personal income limit that enables an individual to retain Supplemental Security Income-linked Medi-Cal coverage when their earnings go above the state's threshold amount. Social Security will determine an Individual Threshold Amount if the individual has Impairment Related or Blind Work Expenses, a Plan to Achieve Self-Support, a publicly funded personal attendant, or medical expenses above the state average amount.

A program that provides domestic, paramedical, and personal assistance services for people with disabilities so that they can live independently or maintain employment safely. The IHSS program provides an alternative to living in an institution for many people.

Cash or other property which can be converted to cash within 20 days, excluding non-work days. Liquid assets include: checking and savings accounts, stocks, bonds, mutual fund shares, promissory notes, mortgages, and life insurance policies.

The amount of an individual’s income that Medi-Cal determines is used to cover living expenses such as food, clothing and housing.

Health insurance for Californians who are unable to obtain coverage in the individual health insurance market, usually due to pre-existing condition exclusionary periods.

A program that allows individuals working with a disability to retain Medi-Cal (Medicaid) coverage through premium payments. In California, this program is called the Working Disabled Program.

California's Medicaid program. It offers health coverage for people with low incomes. There are additional ways to qualify for people who are disabled, blind, or at least 65 years old.

A state program that pays for private health insurance premiums.

A Medi-Cal eligibility category that allows you to have countable income up to 250% of the Federal Poverty Level. 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.

Combined managed care plans for some people with both Medicare and Medi-Cal. These plans exist in some California counties.

Read more about combined managed care for Medicare and Medi-Cal or call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.

Medicare Savings Programs are programs that help people with low income pay for their Medicare expenses, such as Medicare Part A and Medicare Part B premiums, coinsurance, and deductibles. There are four Medicare Savings Programs:

  • The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,255 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles. Note: If you have disability-based or SSI-linked Medi-Cal coverage, you automatically qualify for QMB.
  • The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,506 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
  • The Qualified Individual-1 program, also called QI-1, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,695 per month or less if you live alone). QI-1 helps pay for the Part B premium, but does not help with anything else.
  • The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,550 per month), but have countable income that’s 200% of FPG or less ($2,510 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.

For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.

Learn more about MSPs.

No more Medi-Cal/MSP resource limits

On January 1, 2024, Medi-Cal resource limits were completely removed. This applies to Medi-Cal through A&D FPL, the Working Disabled Program (WDP), and ABD–MN, as well as Medicare Savings Programs (MSPs). If you've been denied Medi-Cal or an MSP because you had too much in resources, try applying again.

Note: This doesn't change SSI-linked Medi-Cal or Medi-Cal through SSI 1619(b), as they still have SSI's $2,000 resource limit. And it doesn't change income-based Medi-Cal, which never had a resource limit.

An evaluation that measures an individual's ability to complete activities of daily living (dressing, toileting, bathing, eating, respiration, getting around in the house) and instrumental activities of daily living (housekeeping, shopping, taking medication, meal preparation, managing finances, and getting around out of the house). The needs assessment determines an individual’s level of need for the In-Home Supportive Services Program.

The portion of an individual's earned income that is taken into account when evaluating financial eligibility for Medi-Cal.

Medi-Cal that you don't have to pay for.

The official name for correspondence between Medi-Cal and beneficiaries.

The insurer who pays medical claims last when an individual has multiple sources of health coverage.

A regularly scheduled payment to an insurer or health care plan.

Agencies to which you need to report any changes in your income or living situation, if you get public benefits.

If you're on Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), call Social Security at 1-800-772-1213 or 1-800-325-0778 (TTY), or visit your local Social Security office, and ask what's the best way for you to report. Note: Reporting rules for SSI and SSDI are different and if you get both benefits, you must report income for them separately.

If you're on Medi-Cal or any other state health coverage or cash assistance program, report any changes in earnings to your county social services agency.

The following items do not count as resources:

  • The home, and any adjoining land
  • Household goods and personal effects that have a total value of $2,000 or less
  • One car if it is: necessary for employment, or necessary for medical treatment, or modified for use by a disabled person, or it provides necessary transportation to perform essential daily activities, or has a current market value less than $4500
  • Property of a trade or business that is essential for self-support
  • Non-business property which is essential to self-support
  • Resources of a blind or disabled individual necessary to fulfill an approved PASS
  • Certain stocks held by Alaskan natives
  • Life insurance, if the total face value of all policies on one person do not exceed $1500. Otherwise, the cash surrender values of life insurance policies will count as a resource
  • Restricted allotted Native American lands
  • Payments or benefits paid under other Federal statutes
  • Disaster relief assistance
  • Burial space of any value, and burial funds up to $1500
  • Title XVI (SSI) or Title II (SSDI) retroactive payments for 6 months
  • Housing assistance
  • Earned Income Tax Credits
  • Nine months of payments received as compensation for expenses or losses suffered as a result of a crime
  • Nine months of reallocation assistance

The amount of money an individual pays for health care costs before Medi-Cal coverage begins.

A Medi-Cal eligibility category that gives free Medi-Cal to those on SSI.

A person who is:

  • Born in one of the 50 states, Washington D.C., Puerto Rico, Guam, Northern Mariana Islands, U.S. Virgin Islands, American Samoa, or Swain’s Island
  • Born outside of the U.S. to at least one parent who is a U.S. citizen
  • Granted citizenship status by U.S. Citizenship and Immigration Services (USCIS)

When applying for benefits, contact the agency you are applying to to find out what documents are acceptable for proving citizenship.

Funds received from sources for which no paid work activity is performed. Disability benefits such as SSDI, SSI, short-term disability insurance, and long-term disability insurance; VA benefits; Workers' Compensation; income from a trust or investment; spousal support; dividends, profits, or funds received from any source other than work are all usually considered unearned income.

Physical or mental activity that is actually performed and results in earned income.