Medi-Cal with a Share of Cost (SOC)
Lower your Share of Cost with Medi Gap or Dental Coverage
Ways to lower your Medi-Cal #Share of Cost
Get a, Life, Dental or Medi Gap Policy
You can Avoid a Share of Cost in the (ABD-MN) Aged, Blind and Disabled – Medically #Needy Program program and then qualify for no-cost A&D FPL. Just purchase
- Medi-Gap or other private health insurance product, including
- Note that if you have Kaiser or another Medicare Advantage Program, you can’t get Medi Gap
- Part D Rx,
- Do you have this in your Medicare Advantage Program?
- Final Expense – ask about the plans that are guaranteed issue, just don’t pay full benefits for say 3 years & Life Insurance?,
- dental or vision insurance get quotes.
Footnotes * Wikipedia * Investopedia * Merriam – Webster * Things to know about Share of Cost * HICAP *
You can deduct the cost of that policy or product and that may help them get under the strict income limit in the A&D FPL and Blind FPL programs. See above, you must have original Medicare, not Medicare Advantage.
If your purchase private health insurance with coverage that duplicates Medi-Cal coverage, the private health coverage would be billed first and then Medi–Cal would pay for the services it covers after the private health carrier pays or denies a claim. Our webpage on Dual Coverage * Western Center Law & Poverty Guide for Low Income Americans * CA Code of Regulations 22 § 50555.2 * Health Care Rights.org *
#Guaranteed Issue Rules to Get Medi Gap
- Here’s a video explanation of our research on how one might get Medi Gap even if they are not healthy. If you have a Medicare Advantage plan, see also Situation # 17
- Visit our Medi Gap Guaranteed Issue Page
- Problems getting Medi Gap if you have full benefits Medi Cal?
Explanation of Share of Cost #SOC
If your monthly income is higher than the limits to qualify for SSI or the A&D FPL program, but you meet the criteria of the low asset-level requirements, you may still qualify and be eligible for Medi-Cal with a share of cost (SOC).
SOC functions like a deductible, it’s not a percentage, like a Co-Pay. You must pay this amount in any month you incur medical costs. After your SOC is paid, Medi-Cal will pay the remaining amount of your medical bills for that month.
Note: A SOC is not a monthly premium. It is more like a deductible. It is the amount of medical expenses you are responsible to pay for before you can get full Medi-Cal coverage for the remainder of the month. If you have no medical expenses, you pay nothing.
More detail on how & where to pay your share of cost when you have IHSS In-Home Supportive Services Scroll down and see our references & links too.
VIDEO Med-Cal FAQ: What Is Share Of Cost? Can I Eliminate It?
To be eligible for the A&D FPL or the Blind FPL Medi-Cal programs, an applicant’s Countable Income for SSI Program cannot exceed a level set by the state that is based on the Federal Poverty Level. The countable monthly income limit for an individual adult or child is based upon the Federal Poverty Level (100% FPL), plus $230.37 Welf. & Inst. Code § 14005.40(c)(1) See Western Poverty Law Page 91 for what seems like the best and understandable explanation
SOC Share of Cost is calculated or determined by using your monthly income, with this formula:
Medi-Cal subtracts $600 (for an individual) or $934 (for a couple) from your monthly income, and any other health-insurance premiums you may be paying.
For example, if you have an individual
monthly income of $1,300,
Medi-Cal subtracts – $600
for a SOC of = $700.
This means you must pay at least $700 in covered medical expenses and/or health care premiums in a given month before Medi-Cal covers any of your health care costs for that month. For people with a high SOC, Medi-Cal is mostly a form of catastrophic coverage, meaning Medi-Cal will most likely only help them for emergencies or high-cost medical conditions. Check out CHCF for 3 other examples!
Note: If you have Medi-Cal with a SOC, Medi-Cal will not pay your Medicare Part B Doctor visits monthly premium. This means your Part B premium will be deducted from your Social Security check each month. One exception applies if you are in a Medicare Savings Program (MSP) that pays for your Part B premium (QMB, SLMB or QI). If you are in one of these MSPs, you will not be affected.
If you meet your SOC with medical costs in any given month, Medi-Cal will retroactively pay your Part B premiums for the month(s) in which the SOC is met. Medi-Cal will send the payment to the Social Security Administration (SSA), which will refund you the amount of the premium. Any Part B premium refund Western Poverty Law * CA Health Care Advocates * Read the full article from CHCF * AB 715 Fact Sheet *
Share of Cost still applies, but only in certain situations. Mainly in the case of disabled adults or those over 65. per 12.10.2014 email from sheinberg law group.com
Share of Cost & Skilled Nursing
Lower your share of cost by getting a Medi Gap policy.
Links & Resources
- California Code of Regulations
- CHFC explanation of Share of Cost
- Legal Aid of San Mateo is your Share of Cost Calculated Correctly
Federal Poverty Level &
Medi-Cal? Covered CA Subsidies? Enhanced Silver?
References & Links
- CHCF explanation SOC Share of Cost Rev December 2017
- CANHR Aged & Disabled Program
- CA Health Care Advocates
- Health Consumer Alliance Fact Sheet
- Disability Rights CA Share of Cost – Nursing Home Resident
- Bridget MacKay Law
- Medi-Cal What it means to you Phamplet
- Covered CA Agent Certification Circa 11.2013 Page 5 et seq)
- Health Rights Hotline. Our number is 1-888-354-4474.
- 1-800-952-5253 to get a fair hearing
- Medi-Cal Contact Info
- Working Disabled Program – Premium may be less than Share of Cost
- Nolo – Spend Down
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VIDEO Seminar - Introduction to #MediGap
- 2022 Official Medicare Guide to choosing a Medi Gap Policy # 02110
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Medi Gap pays the medical expenses that Original Medicare Part A (Hospital) and Part B (Doctor) doesn't. Check out the chart on this page to see what Medicare Pays, what you pay and what a Medi Gap plan pays.
Original Medicare, Medicare Advantage nor Medi Gap pay for long term care either in a nursing home or at home care. Get more information on Long Term Care here. Even if you think you can't afford any extra premiums, there's a lot of valuable information to help with planning.
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- Medi Cal Explained CHCF
- Our Webpages on
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- Denti Cal
- Medi-Cal – MAGI Income Eligibility Criteria
- Aged and Disabled Federal Poverty Level Program
- Contact Info – Complex Questions – Reference Materials Medi-Cal
- Dual Coverage? Medi Cal, Employer Group, Individual, Cal Medi Connect & Medicare
- Full Scope Medi-Cal – Benefits & Coverages
- Transitions from Medi-Cal to get Covered CA
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Dental For #Everyone,
has an excellent website with full brochures, Instant online quoting and enrollment
- One of our colleagues on how Dental for Everyone Works.
- Some of our webpages on dental
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2023 Everything you want to know
- Steve's Video Seminar Introduction to Medicare & You
- Audio from Medicare.Gov
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- Your Medicare #Benefits # 10116
- Don't like computers? Prefer a printed version be mailed to you? Audio MP 3
- Inpatient ONLY - How Medicare Pays for your Surgery Part A vs Part B Very Well Health.com
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#Understanding Medicare Advantage Plans (PDF) #12026
Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan. MAPD Plans must cover all A & B services Medicare.Gov *
That's why the premium is very low or ZERO!
- Set a phone or Skype Meeting
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- MANDATED wording!: Think Advisor * ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’
- We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!
- FYI a 4.27.2022 HHS Office of the Inspector General report found that MAPD plans denied 13% of prior authorizations that would have been covered under original Medicare (Conversely, Medi Gap, just follows what Medicare pays.)
- 88% of MAPD enrollees are happy
MAPD plans often include Dental & Part D - Rx Prescriptions and often have NO premiums! How is that possible? The Federal Government pays them around $700/month to handle your medical care. You must continue to pay your Medicare Part B premium of about $170/month. It's best to apply when you turn 65 for the supplement plans or advantage plans, as that's the main "Open Enrollment" period, guaranteed issue for any plan.
Medicare Advantage Plans also have an annual open enrollment now known as AEP Annual Election Period October 7 to December 15th.
Additional Coverage is important as Medical Bills are increasing Seniors Credit Card Debt or leading to possible bankruptcy?
Does veteran aid & attendance or death benefits as unearned income count towards share of cost?
Your question is beyond our pay grade. Which is Zero. We don’t make a nickel unless you were to get a Medi Gap plan where we make say a 10% commission, paid by the Insurance Company, so there is no additional charge to you.
Thus, here’s our research, not legal advise.
The simple answer is MAGI Income, what’s on the Tax Return…
What if one has a million dollar income from investments? That’s unearned, right?
To be eligible for the A&D FPL or the Blind FPL Medi-Cal programs, an applicant’s countable income cannot exceed a level set by the state that is based on the Federal Poverty Level. The countable monthly income limit for an individual adult or child is based upon the Federal Poverty Level (100% FPL), plus $230.37 Welf. & Inst. Code § 14005.40(c)(1)
See Western Poverty Law Page 91 for what seems like the best and understandable explanation
Countable Income for SSI Program
Income is anything you receive during a calendar month and can use to meet your needs for food or shelter. It may be in cash or in kind.
In-kind income is not cash; it is food or shelter, or something you can use to get food or shelter.
Countable Income definition
Countable income is the amount left over after:
Eliminating from consideration all items that are not income; and
Applying all appropriate exclusions to the items that are income.
Countable income is determined on a calendar month basis. It is the amount actually subtracted from the maximum Federal benefit to determine your eligibility and to compute your monthly payment amount.
(a) Gross unearned income includes:
(6) Veterans payments which include:
(A) Pensions based on need.
(B) Compensation payments.
(C) Educational assistance.
Section 50507 – Gross Unearned Income
California Code of Regulations Article 10 Income Section 50501 – 50571
My elderly mother has dementia and we applied to In home supportive services with a Medi Cal share of cost of $993 dollars
to qualify for full medi cal she would need to purchase $111 in extra insurance a month and
she currently has AARP united healthcare Medicare Advantage insurance.
Due to pre existing conditions and medical underwriting we are having trouble trying to switch to traditional Medicare with a Medicap supplement and
we are wondering what other insurance options could qualify her for full medi cal with no share of cost.
See situation # 16 above, it looks to me like you can get Medi Gap guaranteed issue.
Here’s a video explanation of our research and answer to your question.
You can also get dental & vision coverage.
I will grant that it’s very confusing on the time periods that you can enroll or exit a Medicare Advantage Plan.
So, if you want Medi Gap, you might enroll in a Part D Rx plan. That would then cancel your MAPD with AARP. Then you could enroll in Medi Gap guaranteed issue.
Let me know if you want to do this, send all of the documentation from Medi Cal and I will double check with the higher ups in the “Chain of Command.”
Do you have LIS Low Income Subsidy, to help with Part D Rx costs?
Excerpt from Medicare.Gov Publication 11219
How does Medi-Cal share of cost work with Medicare Part D Rx Prescription coverage?
2. Prescription Drugs
If you are receiving both Medicare and Medi-Cal benefits, the Medicare Part D drug benefit will provide your prescription-drug coverage instead of Medi-Cal. You must be enrolled in a Medicare Part D drug plan or a Medicare Advantage prescription drug plan to get these benefits. (Note: if you are in Cal MediConnect, you will get your prescription drugs through your Cal MediConnect managed care plan.) Medi-Cal, however, will pay for certain categories of drugs not covered by Part D, including:
With Medicare Part D drug coverage, you must make copayments of no more than $1.30 for generic drugs and $8.95 brand name drugs in 2020. The Low-Income Subsidy (LIS) program, also known as the “Extra Help” program, will pay for part or all Medicare Part D drug-benefit plan premiums, depending on the plan in which you are enrolled. Learn more about the Extra Help program and the Medicare Part D drug benefit. https://cahealthadvocates.org/low-income-help/medi-cal-for-people-with-medicare/#Prescription
I need to understand income levels on Covered CA chart for the Silver 94 plan.
I have seen some info that specifies Inc level can be as low as approx $11,500 or 100% of poverty level if not eligible for
‘full-scale scope of benefits Medi-Cal‘.??
The reason that the Covered CA Income – FPL chart below used to show Share of Cost or Cost Sharing Reduction (CA Health Care Foundation 2010 Report) above 100% is
If the member’s income is less than >138% to less than <150% they qualify for Enhanced Silver 94.
The earlier chart shows less than > 100% as in some states, NOT California, Medi-cal is for those under <100%. excerpt of 8.4.2015 email California has adopted Medi-Cal expansion, so in CA if you make less than 138% of FPL you get Medi-Cal, not Cost Sharing Reduction – Enhanced Silver.
because Medi-Cal requires participants to pay Share of Cost if they make more than 100% of the FPL. If they make below 100%, at that point Medi-Cal will absorb complete cost for coverage. If you have any other questions, please let us know. Email Rec’d from Covered CA 11.28.2014 12:15 PM
I applied for Medi-Cal on November 1, 2017 but the application is pending a “shared” cost approval.
Steve Shorr says:
Try contacting your local county see link above or use menu to find the contact page.
My current pay stub as of last week says I made 21,314.05 that’s including Holiday Vacation OT & sick pay & my regular earnings are 19,922.42 I have 2 children & I am receiving CAL-fresh I have been receiving Medi-cal & now it’s redetermination time will I still qualify for benefits?
Steve Shorr says:
February 20, 2017 at 11:01 am
Probably. It appears that your family income is below 138% of Federal Poverty Level. See chart, complementary quote and subsidy calculation in webpage above
Is medi-cal shared cost based on total monthly income if the person passes away during the month and the income is reduced ?
Do You Have to Pay a Share of Cost?
If you do not get one of the above types of Medi-Cal, you may still be able to get no-cost IHSS if your countable monthly income is less than the SSI monthly benefits rate in California — $943.72 for an individual or $1,582.14 for a couple in 2020. (We’ll explain more about how countable income is calculated below.)
If your countable monthly income is above the SSI benefits rate, you can still get IHSS if you meet all other eligibility criteria. You may, however, would have to pay a share of cost. CA.db101.org
The amount of income that Social Security or the state counts when figuring out if you qualify for benefits and, if so, the level of benefits you should get. Not all of your income counts.
Example: Supplemental Security Income (SSI) counts most unearned income, but a bit less than half of earned income. So, if you have $500 in unearned income and $500 in earned income, your countable income for SSI would be just $697.50, even though your total income would be $1,000. Other programs, such as disability-based Medi-Cal and Medicare Savings Programs often use calculations similar to SSI’s.
This is a rather complex question, even though it sounds simple enough. Please double check, whatever we find with Medi-Cal – Contact Info.
Here’s a sample form to complete to determine share of cost.
How exactly is Linda’s Medi-Cal share of cost calculated?
Each year, as my disabled wife’s social security income goes up by a few points, we wait for a letter to see if she has a share of cost, and then adjust her insurance premiums accordingly.
This doesn’t always work, and twice now I’ve had to file an appeal to get the share of cost calculated correctly.
’m usually given a pass/fail judgement, with little transparency as to how this is calculated.
It would be great to know precisely how this is calculated.
Of course, the choice I think I am making here is
a) no extra insurance beyond Medicare, but then she must pay a share of cost (with no extra coverage benefit) vs.
b) pay for additional coverage at a lower cost than the actual share of cost, and which sets her share to nil.
Am I making a smart decision within this framework?
See our response about High Deductible F Medi Gap
See our page on Medicare Advantage MAPD
How important is freedom of choice of doctors and hospitals to you? MAPD limits your choices, they have networks, like an hmo.
If I have Share of Cost, can I get a Covered CA plan with Subsidies? APTC
Individuals must show that they do not have other minimum essential coverage in order to qualify for financial assistance through Covered California.
Minimum essential coverage includes:
• Medicare Part A and Medicare Advantage plans;
• Full-scope Medi-Cal programs, including the Targeted Low-Income Children’s Program (former Healthy Families program),43 Medi-Cal Access Program (MCAP – former AIM program), and Refugee Medical Assistance programs administered by Medi-Cal;44
• Comprehensive health care offered by the Veterans Administration;45
• Coverage provided to Peace Corps volunteers;
• Coverage under the Nonappropriated Fund Health Benefit Program from the Department of Defense;
• Self-funded health coverage offered to students by universities for plan or policy years that began on or before Dec. 31, 2014 (for later plan or policy years, sponsors of these programs may apply to HHS to be recognized as minimum essential coverage);46
• State high risk pool coverage established on or before November 26, 2014 in any state;47 • Most employer-sponsored health plans, including COBRA and retiree coverage;
• Plans purchased on the individual market;
• Grandfathered health plans; and Other plans as designated by HHS.
that because certain Medi-Cal programs are not minimum essential coverage, (namely Medi-Cal Share of Cost programs and programs with limited scope of services such as Minor Consent), individuals enrolled in these programs can simultaneously enroll in a Covered California plan with advanced premium tax credits so long as they meet Covered California’s eligibility criteria.
Medi-Cal only covers what Covered California does not, such as In-Home Supportive Services, adult dental, or long-term care, so individuals should check provider networks before picking a Covered California plan for most regular health services. https://wclp.org/wp-content/uploads/2016/06/Western_Center_2016_Health_Care_Eligibility_Guide_Full_rev.1.pdf#page=156
My Dad is in skilled nursing but WILL be coming home in a few months.
Medi-Cal says his share of cost is all of his income, less $50 (he gets to keep $50).
The problem with this is that he and I share a rented house. He also has a car payment. Neither of these things are taken into account?
So they don’t take into account that he needs a home to go home to?
You’re questions probably goes beyond my pay grade (Zero). See my reply below.
In the meantime, if you send me privately all the documents, [email protected] I can review and see if I can give you any insight on how to get a lower share of cost, no share of cost, get on Medicare, whatever.
Plans with Covered CA subsidies? Get quote.
With SOC Share of Cost at 770.00 do I need to present the card at routine office visits,or present it only if medical expense is greater than 770.00. ?
Yes, that way you get the Medi-Cal Negotiated Rate.
Do you have another ID card to present to get services?
Are you in a Managed Care Plan?
Also, it let’s Medi-Cal keep track of the “deductible”
If the medical cost is 1000.00, Medicare would pay 80% .
Is the 770.00 covered by that, then, Medi-cal would pay the 20% ?
I do not have part D. Would Medi-cal cover prescriptions for the above situation?
And, if I have a routine office visit and present the Medical card, do I have to pay 770.00 for that one visit during the month?
Let’s check our page on Dual Coverage & Medicare
You’re question goes beyond my pay grade (Zero, I don’t get paid) Try asking [email protected] Please post her response in comments below.
Or Medi Cal and Social Service agencies
If my father has private pay providers in the home or 160 hours per week and IHSS has granted him 90 hours per month how is the share of cost met?
Visit the IHSS webpage
Twice a month, both you and your provider who works for you will receive an “Explanation of IHSS SOC” letter that will tell you how much money to pay the provider. Remember, the SOC is part of provider’s salary. You, as the IHSS recipient, must pay the SOC, if any, to the provider monthly. The SOC may change from month to month.
For questions regarding SOC, contact your Social Worker at (888) 822-9622.