Report changes that affect Medi Cal share of cost
Report changes that affect Medi Cal share of cost

Report Changes That Affect Your Medi-Cal Share of Cost

Do not wait for your annual Medi-Cal renewal when a change may lower—or increase—your Share of Cost.

  • If you begin paying a
    • new dental,
    • vision,
    • Medicare supplement,
    • prescription-drug or
    • other health-insurance premium,
  • report it promptly through BenefitsCal or your county Medi-Cal office
  • Ask the county to review the new premium and recalculate your Share of Cost.
Report Through BenefitsCal Proof and Upload Help Calculate Share of Cost

The California Department of Health Care Services instructions for updating Medi-Cal information state that changes should generally be reported within 10 days.

Annual Renewal Is Not the Same as Reporting a Change

  • Annual Medi-Cal renewal:
    • A scheduled review of the information in your Medi-Cal case.
    • The county may renew your coverage automatically or ask you to complete a renewal form.
    • See my web page — Medi-Cal renewal and redetermination.
  • Reporting a change:
    • A midyear update involving income, insurance premiums, household information or another fact that may affect eligibility.
    • The county may conduct a change-in-circumstances redetermination before the next annual renewal.
    • See my web page —
  • Requesting a Share of Cost recalculation:
    • You are asking the county to apply the updated income, premium or deduction information and calculate the correct Share of Cost.
    • Clearly state that you are requesting a new Share of Cost determination.
  • The distinction between scheduled renewals and midyear changes is addressed in

Your Share of Cost Resets Monthly—but Is Not Automatically Recalculated Monthly

A Medi-Cal Share of Cost applies separately to each month. When a new month begins, the amount that must be met before Medi-Cal begins paying for covered services starts over.

  • Monthly reset:
    • The existing Share of Cost must be met again during a new month when covered medical services are needed.
    • A person who met the Share of Cost last month does not automatically satisfy it for the next month.
  • Share of Cost recalculation:
    • The county reviews updated income, insurance premiums, deductions, household information or other eligibility facts.
    • The county then determines whether the monthly Share of Cost should increase, decrease or be eliminated.
  • The county does not ordinarily perform a new calculation merely because a new month begins. The existing amount may remain in the county’s records until new information is processed, an annual renewal is completed or another redetermination occurs.

What Changes May Affect Your Share of Cost?

Report changes that may affect the income, deductions or other information used in your Non-MAGI Medi-Cal calculation.

  • A new health-insurance premium:
  • A premium increase or decrease:
    • Report the new amount even when the same policy remains active.
    • Provide the new billing notice or premium statement.
  • A policy cancellation:
    • Report when insurance previously used as a deduction ends or is no longer being paid.
    • The county should not continue using an outdated premium deduction.
  • A change in Medicare premiums:
    • Report changes in Medicare Part B, Part D or other Medicare-related premiums paid by the beneficiary.
    • Provide the Social Security notice, Medicare premium notice or billing statement showing the new amount.
  • An income change:
    • Examples include Social Security, pension, wages or disability income starting, stopping, increasing or decreasing.
    • Use my web page — Medi-Cal Share of Cost calculator — to estimate how a change may affect the calculation.
  • A household change:
    • Marriage, separation, divorce, death or another household change may affect the eligibility calculation.

The official DHCS Non-MAGI Medi-Cal Guide explains that applicable health-insurance premium payments may be deducted from income when determining Non-MAGI eligibility.

Insurance Premiums and Medical Bills Are Not Treated the Same Way

  • Recurring health-insurance premiums:
    • May be allowable deductions from income when the county calculates Non-MAGI Medi-Cal eligibility and Share of Cost.
    • Examples may include premiums for health, dental, vision, Medicare prescription-drug and Medicare supplemental coverage.
    • A recurring premium may affect the county’s ongoing monthly calculation.
  • Doctor, hospital, prescription and other medical bills:

Do not describe a medical bill as an insurance premium. Identify what was paid, who received the payment, what period it covered and whether it is recurring.

The county makes the final determination about how a premium, deduction or medical expense applies to an individual Medi-Cal case.

How to Request a New Share of Cost Calculation

  1. Report the change promptly.
    • Use BenefitsCal or contact the county Medi-Cal office.
    • Save the date, confirmation number and a copy of everything submitted.
  2. Explain what changed.
    • Identify the new income, premium, policy, deduction or household change.
    • State the effective date and the amount paid each month.
  3. Request a specific action.
    • Ask the county to add or correct the information in the Medi-Cal case.
    • Ask for a new eligibility and Share of Cost calculation.
    • Ask for a written Notice of Action showing the result.
  4. Upload supporting proof.
  5. Check that the county processed it.
    • Uploading a document does not guarantee that the correct worker reviewed or applied it.
    • Check BenefitsCal and follow up when no written decision is received.

The Medi-Cal Renewal Form MC 217 specifically asks about health-insurance premiums and explains that reporting premiums paid may lower the income Medi-Cal uses.

What Should Your Premium Proof Show?

The county needs enough information to determine that the policy exists, who is covered, how much is paid and when the premium became effective.

  • Name of the insured person:
    • The document should identify the Medi-Cal beneficiary or other applicable covered household member.
  • Name of the insurance company and policy:
    • Include the policy or certificate number when available.
  • Type of coverage:
    • Identify whether the policy is dental, vision, Medicare supplement, prescription-drug or another form of health coverage.
  • Monthly premium:
    • The statement should show the amount actually due or paid.
    • If premiums are paid quarterly, semiannually or annually, ask the county how it converted the payment to a monthly amount.
  • Effective date:
    • Provide the date coverage and the premium obligation began.
  • Proof of payment:
    • A bill may show what is due but not establish that it was paid.
    • Include a receipt, canceled check, bank record or carrier confirmation when requested.

Upload complete, readable documents. Do not submit a cropped screenshot that omits the person’s name, premium amount, effective date or insurance-company information.

Report When the Premium Changes or the Policy Ends

If the county used an insurance premium to lower countable income or Share of Cost, report when:

  • The premium increases or decreases;
    • Provide the new billing statement and effective date.
  • The policy is canceled or terminates;
    • Provide the termination notice or other proof showing the final coverage date.
  • You stop making payments;
    • The county should not continue deducting a premium that is no longer being paid.
  • The insurance company refunds the premium;
    • Explain which months or coverage periods were refunded.
  • Coverage moves to another person;
    • Identify who is now insured and who pays the premium.
  • A different policy replaces the old policy;
    • Report the termination of the old policy and the effective date and premium for the replacement policy.

Outdated information can produce an incorrect Share of Cost, eligibility decision or Notice of Action. Save proof showing when the change was reported.

When Should the New Share of Cost Begin?

The effective date may depend on when the change occurred, when it was reported, whether adequate proof was provided and when the county processed the redetermination.

  • Future-month corrections:
    • Ask the county to explain when the corrected calculation will take effect.
    • Review the new Notice of Action to confirm the income, deductions and Share of Cost.
  • Delayed county processing:
    • Keep proof showing when the change and supporting documents were first submitted.
    • Ask whether the county can correct months affected by its processing delay.
  • Corrections for previous months:

Ask for a written decision. A telephone statement does not replace a Notice of Action explaining the county’s calculation, effective date and appeal rights.

What If the County Does Not Correct the Share of Cost?

  1. Review the Notice of Action.
    • Check the income, deductions, household information, Share of Cost and effective date.
  2. Ask for the county’s calculation.
    • Request the figures used to determine countable income and Share of Cost.
    • Compare the county’s calculation with the documents you submitted.
  3. Confirm receipt of every document.
    • Ask whether the premium statement and proof of payment were received and reviewed.
    • Resubmit missing, incomplete or unreadable documents.
  4. Ask how the premium was treated.
    • Ask whether it was accepted as an allowable health-insurance premium deduction.
    • If it was denied, ask for the specific reason in writing.
  5. Request a corrected written decision.
    • Ask the county to issue a new Notice of Action when the original calculation was incorrect.
  6. Review your hearing rights.

Share of Cost Change Resources

The county Medi-Cal office makes the final determination about whether a particular premium, deduction or medical expense applies to an individual Share of Cost calculation.

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