You can think of Medi-Cal as a single program that you can qualify for in many different ways. These different ways are called eligibility categories. For example, SSI-Linked Medi-Cal is an eligibility category that allows people who qualify for SSI to automatically get Medi-Cal. There are over 90 eligibility categories, each with its own rules and requirements. Once you meet the requirements of an eligibility category, you are eligible for either full or partial-scope Medi-Cal.

DB101 describes the most common eligibility categories for people with disabilities:

How to Apply

There are different ways to apply for Medi-Cal:

• Online using BenefitsCal. BenefitsCal lets you apply for other programs like CalFresh or CalWORKs at the same time.
• Online using Covered California, an online one-stop shop where you can learn about your public and private health coverage options.
• In person at your local county social services agency.
• Using a paper application (available in 11 languages) and mailing it in to your local county social services agency.

Note: If you get Supplemental Security Income (SSI) or used to and now are on SSI 1619(b), you automatically get Medi-Cal coverage. You do not need to apply for Medi-Cal.

If You Are Approved

Usually, if you are approved for Medi-Cal, you get your health coverage through a managed care program. There are different managed care programs in each county operated by insurance companies and local non-profits.

Having Medi-Cal through a managed care program means that you have a primary care physician who you see for most of your health needs. When you need to see a specialist or have a test done, you usually have to get a referral from your primary care physician. With managed care programs, you have limited options for which specialists and hospitals you can visit, but if you have an emergency, you can go to any hospital.

Note: If you do not have Medi-Cal through a managed care program, you will probably have to switch to managed care in the future.

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:

• Don't qualify for Medicare, and
• Are a a U.S. citizen or a qualifying immigrant

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) ($20,120 for an individual; $41,400 for a family of four).
• You are a child 18 or younger and your family’s income is at or below 266% of FPL ($79,800 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 ($42,004 if you are single and pregnant with your first child, $63,900 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.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$14,580
	$5,140
	$13,590
	$4,720
	$14,580
	$5,140
Income-based Medi-Cal, adults (138% FPG)
Income-based Medi-Cal, children (266% FPG)
Subsidized private plans, reduced fees (250% FPG)
Subsidized private plans (no income limit)	--
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

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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:

• Aged & Disabled Federal Poverty Level Medi-Cal (A&D FPL)
• SSI-linked Medi-Cal and SSI 1619(b)-linked Medi-Cal
• Medi-Cal's Working Disabled Program, and
• Aged, Blind, & Disabled Medically Needy Medi-Cal (ABD–MN)

These ways to qualify are explained here.

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 $130,000 in assets ($195,000 for a couple). Like SSI, this program does not count all of your assets. Click here for a list of exemptions.
  

  • Note: If your disability began before you turned 26, you can open an ABLE account and save up money without having it counted by Medi-Cal. Learn more about ABLE accounts.
• Have less than $1,677 in countable monthly income for an individual ($2,268 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)	$
	20.00
	65.00
Your Monthly Countable Income

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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 $1,677 for individuals or $2,268 for a couple, then you qualify for free, full scope Medi-Cal based on A&D FPL rules.

If it is higher than $1,677 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.

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.

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 and having resources below $2,000, and
• Make less than $56,758 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.

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 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.
3. Have assets worth less than $130,000 for an individual ($195,000 for a couple). The same asset exclusions apply for this program as for A&D FPL Medi-Cal except for a couple of major differences:
   • Retirement funds like a 401(k) or Individual Retirement Account (IRA) are not counted as assets for this program.
   • If you are enrolled in the program, you can save earnings in a separate bank account and this money will not count against the program’s resource limit. There is no limit to how much of your earnings you can save this way and still remain eligible for Medi-Cal.
     • Note: If you ever need to qualify for a different Medi-Cal program that has a resource limit, the earnings you saved in this account while on WDP will not be counted as resources.
     • Tip: If your disability began before you turned 26, you can open an ABLE account and save up money without having it counted by Medi-Cal. Learn more about ABLE accounts.
4. Have countable income less than 250% of the Federal Poverty Level ($3,038 per month for individuals and $4,108 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 $73,920 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 ($3,038 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)	$
	20.00
	65.00
Your Monthly Countable Income

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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.

Medi-Cal eligibility categories have complicated rules for how much money you can earn. So, when your income changes, it may affect your eligibility for Medi-Cal coverage. There are, however, a number of programs designed to help you keep your coverage when your income goes up.

Working Disabled Program

If you’re receiving free Medi-Cal and your income goes up because you are working, you may be eligible to switch to the WDP program. Medi-Cal workers are required to automatically check to see if you are eligible for this program when your income disqualifies you from your eligibility category. If they don’t, you should ask them to. You’ll have to begin paying for your Medi-Cal coverage, but the amount is small compared to the income you’re earning. See above for a description of this program.

SSI’s 1619(b) Provisions

If you’re on SSI-Linked Medi-Cal, and then your SSI benefit goes to zero because you go back to work, a section of the SSI regulations called the 1619(b) provisions allow you to keep your Medi-Cal coverage. In order to continue your Medi-Cal coverage under this program, you must:

• Have been eligible for an SSI cash payment for at least 1 month
• Still meet SSI requirements, like disability, blindness, or age, that don’t have to do with income
• Need Medi-Cal coverage to continue working, and
• Have less than $56,758 in gross earnings ($55,439, if blind) or have high medical expenses that will be evaluated on a case by case basis. Note that this program does not use the countable income calculation.

The $56,758 income limit is called a threshold amount. This is what Social Security calculates as the value of your SSI and Medi-Cal benefits. They determine this based on the SSI benefit in California, along with averages of medical costs in the state. So, if you’re earning enough money to replace the benefits and cover your medical costs without help from the government, then you’re usually not eligible for the program.

If your expenses are higher than the state average, Social Security may increase the threshold on a case-by-case basis. If you have IRWEs, BWEs, are contributing to a PASS, have a publicly funded personal assistant, or have medical expenses higher than the state average, you may be eligible for an individual threshold amount.

Pickle Amendment

When calculating your countable income, SSI considers any Social Security Disability Insurance (SSDI) or Childhood Disability Benefits benefits as unearned income. SSDI and CDB benefits increase every year to cover cost of living increases. This increase may be enough to make you ineligible for SSI, and the Medi-Cal linked to it. The Pickle Amendment protects Medi-Cal coverage for people in this situation. In other words, if you lose your SSI benefit because of a cost of living increase in your SSDI or CDB benefit, you can keep your Medi-Cal.

For more information, see Health Consumer Alliance’s excellent pamphlet on the Pickle Amendment.

If your income goes up so much that none of these rules help you keep your Medi-Cal and you cannot get coverage from an employer, you may qualify to get government help paying for a private health coverage plan on Covered California. If your family’s income is at or below of the Federal Poverty Guidelines (FPG), $33,975 for an individual ($69,375 for a family of four), the federal government will also help you get a plan that has lower copayments and other expenses.

Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG for federal subsidies and 600% of FPG for state subsidies.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$14,580
	$5,140
	$13,590
	$4,720
	$14,580
	$5,140
Income-based Medi-Cal, adults (138% FPG)
Income-based Medi-Cal, children (266% FPG)
Subsidized private plans, reduced fees (250% FPG)
Subsidized private plans (no income limit)	--
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

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See DB101's Buying Health Coverage on Covered California article for more information.

Besides health care services, Medi-Cal also pays for health insurance premiums in certain circumstances. There are a number of premium payment programs, organized into the following two categories:

Medicare Savings Programs

Medi-Cal (or Medi-Cal's Working Disabled Program) may help pay your Medicare Part B premiums.

And, depending on if you qualify, four additional Medi-Cal programs can help pay for more Medicare premiums, copayments, or deductibles. These programs are known as Medicare Savings Programs or Medicare Buy-Ins.

Each program has specific income limits and pays for different Medicare costs:

The Qualified Medicare Beneficiary (QMB) program pays for Medicare Part A and Part B premiums, coinsurance and deductibles. To qualify, an individual must:

• Be eligible for Medicare Part A and Part B
• Have countable income at or below 100% of the Federal Poverty Guidelines (FPG) ($1,215 per month, $1,644 for couples)
• Have resources at or below the limit ($130,000 for individuals, $195,000 for couples).
• Meet Medi-Cal requirements besides income and assets limits

This program does not apply benefits retroactively.

The Specified Low-Income Medicare Beneficiary (SLMB) program pays for Medicare Part B premiums. To qualify, an individual must:

• Be eligible for Medicare Part A and Part B,
• Have countable income at or below 120% of FPG ($1,458 per month, $1,972 for couples)
• Have resources at or below the limit ($130,000 for individuals, $195,000 for couples)
• Meet Medi-Cal requirements besides income and assets limits

The Qualified Individual-1 (QI-1) program pays for Medicare Part B premiums. To qualify, an individual must:

• Be eligible for Medicare Part B
• Have countable income that's higher than 120% of FPG, but at or below 135% of FPG (between $1,458 and $1,641 per month for individuals, and between $1,972 and $2,219 for couples)
• Have resources at or below the limit ($130,000 for individuals, $195,000 for couples)
• Meet Medi-Cal requirements besides income and assets limits

The Qualified Disabled Working Individual (QDWI) program pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their SSDI and Medicare benefits due to earnings above the SGA amount. To qualify, an individual must:

• Be less than 65 years old
• Still be disabled
• Still be eligible for Medicare under a work incentive program
• Have countable income at or below 200% of FPG ($2,430 per month for individuals, $3,287 for couples)
• Have resources at or below the limit ($130,000 for individuals, $195,000 for couples)
• Not be eligible for Medi-Cal

SSDI has rules that encourage you to return to work. After your SSDI benefit ends, you will still receive free Medicare benefits for 93 months. After that period ends, you may want to consider the QDWI program.

Call your county Health Insurance Counseling & Advocacy Program (HICAP) office to learn more about whether you qualify for a Medicare Savings Program. If you do, they'll explain how to apply at your local county social services agency.

Learn more about how Medi-Cal can help you pay your Medicare expenses in DB101's Medicare article.

Medi-Cal’s Health Insurance Premium Payment (Medi-Cal/HIPP)

There are certain situations when Medi-Cal will pay for private health insurance premiums. This program is for people who:

• Are on Medi-Cal,
• Also have private health insurance, or have private coverage available,
• Have a high cost medical condition, AND
• Have lost (or are about to lose) private coverage

The idea is that when you lose your private insurance, Medi-Cal can either pay for your medical expenses or pay for you to keep your private coverage. Medi-Cal will do whichever costs less. If you currently have private health insurance, the program is called Health Insurance Premium Payment (HIPP). If you have private coverage available, but aren’t using it, the program is called Employer Group Health Plan (EGHP). Besides the difference in names, the programs are otherwise identical and are usually simply referred to as Medi-Cal/HIPP.

To qualify for the Medi-Cal/HIPP program, you must:

• Be on Medi-Cal
• Have a high cost medical condition
• Have available, or be currently using, group health coverage, COBRA, or a conversion policy. A conversion policy is one where you converted a private group policy into a private individual policy
• Apply for Medi-Cal/HIPP within 30 days of your coverage ending (20 if you’re using a conversion policy)
• Have a policy that covers your high cost medical condition
• Not be part of a pre-paid or county health plan (County Health Initiative, Geographic Managed Care, County Medical Services Program)
• Not be covered by Medicare or TRI-CARE (formerly known as CHAMPUS)
• Not be covered through the MRMIP program

Medi-Cal should evaluate your eligibility for Medi-Cal/HIPP when you indicate that you have insurance available but haven’t applied for it, that you are about to end your health insurance, or that your policy has lapsed. To apply, you’ll need to provide forms from your insurance company describing your benefit and a diagnosis signed by your doctor.

If you are eligible for Medi-Cal/HIPP, you will still be on Medi-Cal. The only change will be for those who did not previously have private coverage. If that’s the case, Medi-Cal will become the payer of last resort. If you are accepted into the Medi-Cal/HIPP program you must participate or else you can lose your Medi-Cal eligibility. Your eligibility for the program is reevaluated every year.

Other Information

Some examples of high cost medical conditions are AIDS, asthma, cancer, diabetes, heart disease, paralysis, and pregnancy. There are many others, and Medi-Cal evaluates applications on a case-by-case basis.

Michael's Story

Michael is 35 years old and lives with his parents. Last year, during a routine physical exam, he found out that he has cancer of the lymph nodes in his neck. The cancer has not responded to therapy, and he hasn’t been able to work for the last 9 months. Although he’s getting $980 a month in State Disability Insurance, he is starting to worry about staying afloat financially. He already knows that he does not qualify for Social Security Disability Insurance (SSDI) because he has not worked enough in the past. He asks around for advice, and a friend recommends that he find out if he is eligible for Medi-Cal. Michael finds his local county social services agency and makes an appointment with a case worker named Melissa.

Michael gets there early and reads through a few brochures about Medi-Cal. He sees a brochure about being able to enroll in a program called Supplemental Security Income-Linked Medi-Cal. When he and Melissa sit down to discuss his case, it’s the first thing he asks.

“Well,” Melissa says, “that depends on your situation. Why don’t you tell me a little bit about yourself?”

Michael explains his medical condition and that he is getting $980 in SDI. Melissa shakes her head.

“For the SSI-Linked Medi-Cal program, you have to meet all of the requirements of the SSI Program. It seems like you would meet everything except for the income limits. Basically, you can’t have an income that’s higher than the maximum SSI benefit amount. In your case, that amount is $833.89."

Melissa pulls out a table showing SSI benefit amounts and points to a line that says, ‘Single person living in the household of someone else.’ You have $960 in countable income, which is over the limit.”

“Wait a second. I have $980 in SDI benefits. Why did you say that I only have $960 in countable income?”

Melissa explained that Social Security doesn’t count all of your income when figuring out if you are eligible for the SSI program. “Instead,” she says, “they use a countable income calculation. For example, they subtract $20 from any unearned income like your SDI check. They also take deductions from your earned income, but since you don’t have any, we won’t go into that right now. In any case, your countable income is too high for SSI, so you can’t get SSI-Linked Medi-Cal.”

Michael looks upset and asks, “So I’m not eligible for Medi-Cal because my countable income is too high?”

“No, you just can’t qualify for SSI-Linked Medi-Cal. There are many other ways to qualify. For example, the Aged and Disabled Federal Poverty Level program allows you to have up to $1,677 in monthly countable income and get free, full-scope Medi-Cal. It looks like you may qualify for Medi-Cal through that program.”

“Why do you say ‘may qualify’? I have less than $1,677 in countable income,” Michael says.

Melissa explains that there is also a limit of $130,000 on resources for an individual and asks Michael if he owns anything or has any assets. “Your home and one car, by the way, don’t count.”

“Nope, just one junky car.”

“Then it looks like you can qualify for free, full-scope Medi-Cal under the Aged and Disabled Federal Poverty Level program.”

Michael looks happy at first, but quickly grows serious again. He has been thinking about going to work and asks Melissa if he can get employer-sponsored health coverage and still get Medi-Cal.

“Absolutely,” Melissa says. “When you go for medical services, your private insurance will be billed first. Anything that they don’t cover will then be billed to Medi-Cal, who will pay for any services that are part of full-scope Medi-Cal.”

Michael relaxes again and Melissa then helps him fill out his application.

Two months later, Michael gets a letter in the mail saying that he has been accepted to Medi-Cal through the Aged and Disabled Federal Poverty Level program. The letter includes his Medi-Cal card, and explains what services are covered and how to use the benefit.

Fourteen months later, Michael, still disabled, begins working part-time earning $3,285 a month in gross income. He is no longer receiving SDI, since that benefit usually only lasts for a year. Even without running through the countable income calculation, he can tell that he’ll be over the income limit for the Aged and Disabled FPL program. He’s worried that he’ll lose his Medi-Cal because of his earned income. He calls and makes another appointment with Melissa. At her office again, she explains that, as he suspected, his income will make him ineligible for A&D FPL Medi-Cal.

Michael asks, “So, I’m out of luck?”

“Not necessarily,” Melissa responds. She explains that there’s something called the Working Disabled Program that allows people to have countable income at 250% of the Federal Poverty Level and keep their Medi-Cal.

Melissa walks him through the countable income calculation, this time explaining the deductions for earned income. “Since you no longer have any unearned income, we take that $20 deduction and apply it to your earned income. There’s another $65 we take off for earned income, and then we divide that by 2. So, if you’re making $3,285 a month,” Melissa says, “then you’ll have $1,600 in countable income ($3,285 - $20 deduction - $65 = $3,200 and $3,200/2= $1,600).

“We’ll start the paperwork to have you switched over to the WDP program.”

“Thanks so much for all of your help, Melissa.”

“You’re welcome!”