Medi-Cal facts for Seniors

Medi-Cal is California’s Medicaid health care program. This is a federal and state-funded health coverage program for individuals with low income and limited assets. Medi-Cal is a government program that pays for health and medical care for older adults aged 65 oo over or disabled individuals who have low income and limited resources.

Medi-Cal pays for:

• Health and medical services when you use a Medi-Cal doctor, provider, or facility
• The Medicare Part B premium

What does Medi-Cal Cover?

• Adult day health services
• Ambulance services
• Dental care
• Doctor visits
• Home health care
• Hospice care
• Hospital and nursing home care
• Medical equipment
• Some categories of medicines and supplies are excluded by Medicare Part D plans, including incontinence supplies.
• Prosthetic/orthopedic devices
• X-ray and laboratory tests

Note: Medi-Cal is the “payer of last resort.” Medicare is primary. If Medicare covers one of these services, generally Medi-Cal  will not pay anything, although by law you cannot be billed for the balance.

How Many Resources You Can Have

Asset limits have increased. A new law means there will be no asset limits in 2024. Applications will not ask for asset information beginning January 1, 2024.

Medi-Cal Eligibility

To be eligible for Medi-Cal with no share of cost, your monthly gross income in 2024 must not exceed $1,732 for an individual and not exceed $2,332 for a married couple. For married couples, when one spouse is in a nursing home, higher resource and income limits apply. Contact Medi-Cal for details.

• Individuals on SSI are automatically eligible for full Medi-Cal
• Individuals who have income over the Medi-Cal limit may still be eligible for Medi-Cal with a share of cost

What is a Share of Cost?

If your income is more than the Medi-Cal income limits, you can still qualify for Medi-Cal but you will have a share of cost.

• A share of cost is not an amount that you must pay every month. Share of cost is like a deductible; it is the share of your medical bills that you are liable for before Medi-Cal pays the rest of your expenses for that month.
• If your medical expenses in a month do not exceed your share of cost amount, Medi-Cal will not pay any of your medical bills. Medi-Cal will pay medical bills that exceed your share of cost amount in a month.
• To find your approximate share of cost, subtract $620 for an individual ($954 for a couple) from the amount of your monthly income along with any health insurance premiums you may be paying (including Part B premium). The result is your share of cost.
• Resource limits for Medi-Cal with a share of cost are the same as those for regular Medi-Cal with no share of cost.
• Medi-Cal will pay the Medicare Part B premium only for the months when the share of cost is met.

Medi-Cal & Medicare Part D

If you are covered by Medi-Cal, you may be entitled to ‘Extra Help’, also known as the Low Income Subsidy (LIS), which helps pay for prescription costs in a Medicare Part D plan.

If you have full Medi-Cal (with no Share of Cost), you do not need to apply for Extra Help. You will be automatically enrolled for the highest level of Extra Help which includes:

• No monthly premium in designated plans
• No deductible
• No coverage gap
• Co-payments between $1.55-$4.60

If you are not in a Part D plan, you will be assigned to a plan. You have the right to change your Medicare drug plan or Medicare Advantage once per quarter if desired.

If you have Medi-Cal with a Share of Cost, you may qualify for Extra Help in one of two ways:

1. Complete and return the Social Security application for Extra Help with prescription drug costs. Social Security will advise you if the application has been approved and what the benefits will be.
2. If you meet your Share of Cost expenses in one month, you are entitled to receive Extra Help on prescription drug costs for the rest of the year. If the Share of Cost is met between July 1 and December 31, you will be considered eligible for Extra Help for the following year as well.

How to Apply for Medi-Cal Benefits?

Call the Santa Clara County Medi-Cal Center at (408) 758-3800 or (877) 962-3633. Ask for the Medi-Cal intake line and say that you want to start your Medi-Cal application over the telephone.

• Have available your Social Security number and birth date
• If you are eligible for Medi-Cal, your benefits will start on the date you called. If you do not start the application process by telephone, your benefits will start on the date you return your application to the address indicated on the form.
• When asked in the Medi-Cal application, if true, state you have medical expenses in order to start the application to start benefits up to three months before your application date

You can also apply in person at the following locations:

1. Application Assistance Center 1867 Senter Rd, San Jose, CA 95112
2. North County Office 1330 W. Middlefield Rd, Mountain View, CA 94043
3. South County Office 379 Tomkins Ct, Gilroy, CA 95020

HICAP can help you understand your options. View our HICAP counseling appointments for more information.

This project was supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $94,686 with 100%funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.