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

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) ($1,255 per month, $1,704 for couples)
• Meet other Medi-Cal requirements besides income

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 ($1,506 per month, $2,044 for couples)
• Meet other Medi-Cal requirements besides income

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 $1,506 and $1,695 per month for individuals, and between $2,044 and $2,300 for couples)
• Meet other Medi-Cal requirements besides income

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 ($2,510 per month for individuals, $3,407 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.