Other Medi-Cal Programs

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

There are four programs that have Medi-Cal pay for 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) ($1,041 per month, $1,410 for couples)
  • Have resources at or below the limit ($7,730 for individuals, $11,600 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 ($1,249 per month, $1,691 for couples)
  • Have resources at or below the limit ($7,730 for individuals, $11,600 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 $1,249 and $1,405 per month for individuals, and between $1,691 and $1,902 for couples)
  • Have resources at or below the limit ($7,730 for individuals, $11,600 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 ($2,082 per month for individuals, $2,818 for couples)
  • Have resources at or below the limit ($4,000 for individuals, $6,000 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.

Combined managed care plans for some people with both Medicare and Medi-Cal

Starting in 2014, some people who qualify for Medicare and Medi-Cal coverage at the same time get their health coverage through combined managed care plans called “Cal MediConnect” plans. That means they have just one card for their Medicare and Medi-Cal and any billing automatically takes into account the benefits both programs provide. This makes things simpler for people with these Cal MediConnect combined coverage plans.

Not everyone on Medicare and Medi-Cal has this option. It's only for people who live in seven California counties: Alameda, Los Angeles, Riverside, San Bernadino, San Diego, San Mateo, and Santa Clara. Most of these counties have more than one Cal MediConnect combined managed care option – so you may just hear it referred to by the names of the insurance companies or non-profits running the plans in your county.

Not everybody gets to choose a Cal MediConnect plan at the same time. If and when you have the option to choose a Cal MediConnect plan, you should get letters from your county with more information. It is important to read these letters, since the plan you choose could impact which doctors you can visit.

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

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.

Medi-Cal/HIPP will not pay for past premiums.

Medi-Cal/HIPP will pay for family members who aren’t on Medi-Cal when it will save money for the state. For example, let’s say that you have private health coverage that also covers your family members. You are not on Medi-Cal, but your family members are. If it saves the state money, Medi-Cal/HIPP will pay for your premiums so that your family members can be on the private policy.