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 $840 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 $840 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 $678.24."

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 $820 in countable income, which is over the limit.”

“Wait a second. I have $840 in SDI benefits. Why did you say that I only have $820 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 $1,271 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 $1,271 in countable income,” Michael says.

Melissa explains that there is also a limit of $2,000 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 by paying a premium.

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). It’s a sliding scale premium, and individuals with countable income between $1,501 and $1,700 pay a premium of $150 a month.”

Michael looks relieved. “With the money I’m making, I can definitely afford that.”

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

“Oh, I’m glad you reminded me,” Michael says. “I will be eligible for health care through work next week. I remember you saying that I can have both Medi-Cal and private coverage, but my employer is going to stop offering health insurance eight to nine months from now and I can’t afford the COBRA premiums. I’m worried that Medi-Cal isn’t going to cover some of the services that my private coverage does. What should I do?”

“Well, there’s a Medi-Cal program called Health Insurance Premium Payments, or Medi-Cal/HIPP. If you meet the requirements, Medi-Cal will pay for your COBRA premiums,” Melissa says.

“That’s great. Why would Medi-Cal do that?”

“Think about it,” Melissa replies. “If you lose your private insurance, then Medi-Cal will have to pay for a lot more of your Medi-Cal expenses, especially if you have a high-cost condition. So it’s sometimes cheaper to pay for the insurance premiums rather then the medical costs. Make an appointment with me a month before your coverage ends, and we’ll get you signed up for the program.”

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

“You’re welcome!”