Share of Cost - CHCF 2010

Medi-Cal with a Share of Cost (SOC
Medically Needy
Lower your Share of Cost with Medi Gap or Dental Coverage

Ways to lower your Medi-Cal #Share of Cost

If you don’t have Full Scope Medi Cal 

Get a Vision,  Dental or  Medi Gap Policy

You can Avoid a Share of Cost  in the (ABD-MN) Aged, Blind and DisabledMedically #Needy Program (CANHR Fact Sheet 8.14.2023) (My highlighted version) program  and then qualify for no-cost A & D FPL.

Just purchase California Code of Regulations :

 

How much  do  I have to spend to eliminate share of Cost?

    • Yeah, it’s very confusing.  Please scroll down and read everything.  Send us your paperwork and we can review, [email protected]

Footnotes * Wikipedia * InvestopediaMerriam – WebsterThings to know about Share of Cost * HICAP *

Introduction to #MediGap

Medi Gap Guide to choosing a plan 2023

Our video explaining the Governments brochure on choosing a Medi Gap Policy.  Click the little square on the right, to enlarge the video.

Get Quote for Medi Gap

Guaranteed Right to get Medi Gap if your #Medi-Cal benefits change...

Guaranteed Issue Rules to Get Medi Gap

Guaranteed right to get Medi Gap

 

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.

Income Limits

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

Cal Matters – Problems with Income Limits – Inflations – Numbers haven’t changed in 30 years.

 

 

 

References & Links

FAQ’s 

Getting additional Insurance to #lower SOC Share of Cost

Question  Hi, My father was approved for IHSS In Home Supportive Services  under Medi-Cal with share of cost. His SOC is $1723 which extremely high. His income from SS and pension is about $2,500. He currently has senior advantage with Kaiser. NO additional insurance. How could he spend $646 in insurance premium to eliminate his share of cost?

Answer  – Please send us [email protected] all the paperwork from Medi Cal so that we can review it.  We will not post any confidential or identifying information.  Would you consider dropping Kaiser to get a Medi Gap plan?

 

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

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!

Clarification from Hi Cap 

 

Hello Mr. Shorr,

Mrs. Burns shared your latest email with me, and I will respond.

  • First, California Health Advocates (CHA) focuses primarily on Medicare issues. We leave the topic of Medi-Cal calculations and regulations for share of cost determination to the appropriate county Medi-Cal office.
  • Second, when Medicare beneficiaries request help from the local HICAP, we encounter the fact that many beneficiaries are very much connected to their Medicare Advantage Plan, and often that works against them if they have a large Medi-Cal Share of Cost (SOC) . Sometimes the only option is to return to Original Medicare during the Open Enrollment (October 15 to December 7), or other Special Enrollment Periods, and try to get a Medigap with a premium that will help them with reducing their countable income. But then as you know, their situation would have to meet one of California’s Guarantee Issue regulations, otherwise they’d be subject to underwriting.
  • Third, if a beneficiary feels that their SOC was not calculated correctly, the HICAP can refer the beneficiary to their Area Agency on Aging partner – Legal Services – for assistance. [Bet Tzedek – Los Angeles]  This is the proper referral as established under the Older Americans Act.

I hope this helps with your concerns, and have to emphasize that CHA does NOT do policy or advocacy work on Medi-Cal related issues.

All the best,

Tatiana

Tatiana Fassieux
Education & Training Specialist
California Health Advocates (CHA)

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Medi Cal out of state #emergency coverage?

 

CA Medi Cal – Out-of-state medical care is limited to the following:

(a) (1) When an emergency arises from accident, injury or illness; or

(2) Where the health of the individual would be endangered if care and services are postponed until it is feasible that he/she return to California; or

(3) Where the health of the individual would be endangered if he/she undertook travel to return to California; or

(4) When it is customary practice in border communities for residents to use medical resources in adjacent areas outside the State; or

(5) When an out-of-state treatment plan has been proposed by the beneficiary’s attending physician and the proposed plan has been received, reviewed and authorized by the Department before the services are provided; and the proposed treatment is not available from resources and facilities within the State.

(6) Prior authorization is required for all out-of-state services, except:

(A) Emergency services as defined in §51056.

(B) Services provided in border areas adjacent to California where it is customary practice for California residents to avail themselves of such services.  texas.gov/medicaid

FAQ’s from Full Scope Medi-Cal

Just merged to this page

 

 

 

See our IHSS FAQ Section

I have been providing IHSS In Home Supportive Services for a friend, we applied for full scope medical

please me on how to follow thru,

My son is disabled, he has a developmental and mental condition. He receives medicare and medi-cal. Could you please let me know if he is eligible for Full Scope Medicare [Medi-Cal].

He needs dental work and according to the dentist he is not covered.

Mother and care taker.

Does he get SSI? That would qualify him for full scope Medi Cal.

See above for information on Dental for Medi Cal

Did your son qualify for Medi Cal under the aged and disabled program?

See the rules in Western Poverty Guide Page 78

This page might be easier to read on CA Health Care Advocates. Do you meet the qualifications?

Here’s contact information for Medi Cal. Do you have an online portal with them? What county are you in?

Try calling Denti Cal 1-800-322-6384

Does Full Scope Medi-Cal work as HMO plan or not?
See above about Mandatory HMO Enrollment

if I got full scope medi cal do I have to purchase supplemental insurance

Depends on what you mean by “supplemental?” The “health” insurance portion of Medi-Cal is pretty comprehensive. Most everything is zero co-pay. Even dental is covered. Take a look at the Summary of benefits for the HMO you get assigned to. See if there are any gaps your concerned about.

I don’t know why they want Medicare for All, with 30 percent of California’s on Medi-Cal, it might look more like Medi Cal for all. Did we get to keep our doctors?

You might want to look at:

Life Insurance, you can get a quote right on this page.

My child wants to play sports at his public school. They are telling me that Medi-Cal isn’t good enough. What can I do?

We are unable to find anything online about high schools requiring health insurance. Please send us they letter from your school.

3. What is the difference in coverage between Medi-Cal and Covered California?​​​​

Medi-Cal is health coverage, just like the coverage offered through Covered California. Medi-Cal provides benefits similar to the coverage options available through Covered California, but often at lower or no cost to you or your family. All of the health plans offered through Covered California or by Medi-Cal include the same comprehensive set of benefits known as “essential health benefits.”

Essential health benefits consist of:

Outpatient (Ambulatory) services
Emergency services
Hospitalization
Maternity and Newborn care
Mental Health and Substance Use Disorder Services, including Behavioral Health Treatment
Prescription Drugs
Programs such as physical and occupational therapy (known as Rehabilitative & Habilitative Services) and devices
Laboratory services
Preventive and wellness services & chronic disease management
Children’s (Pediatric) services, including oral and vision care.

A recent survey of Medi-Cal members by the California Healthcare Foundation (CHCF) found that 90% of respondents rate Medi-Cal as a good or very good program. Medi-Cal emphasizes prevention-oriented health care that promotes health and well-being and works to ensure members receive the right care at the right time.​ dhcs.ca.gov/Medi-Cal FAQs

My client has a share of cost with Medi-Cal of $439, and they currently have IHSS. and IHSS states NO SHARE OF COST

Here’s my question, that is complicated to me.

They also qualify under the Aged-FPL Program which is has NO share of cost.

So does that mean they do not have to Pay the $439 to their Care-provider.

They have a Medicare Part B premium,

an additional policy for vision, and dental as a medical deduction.

Please advised.

Do they have to pay in sharing the cost for a CAREGIVER $439 or NOT

We are in Alameda County.

See our IHSS FAQ Section

See our Medi Cal related pages above
What’s the difference in The Aged-FPL Program, no share of cost, and Medi-Cal with a share of cost.

Which overrides if you have IHSS. In Home Support Services

See our IHSS FAQ Section

24 comments on “Share of Cost – Medically Needy – Lower with Health Insurance Premiums

    • 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?

      Income Limits.

      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 definition

      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

  1. 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.

  2. 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‘.??

    Reply

    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

  3. I applied for Medi-Cal on November 1, 2017 but the application is pending a “shared” cost approval.

    Reply
    Steve Shorr says:

    Try contacting your local county see link above or use menu to find the contact page.

  4. 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?

    Reply
    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

  5. 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

      Countable Income

      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.

  6. 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?

    • 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
      • TRICARE;
      • 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.

      Note

      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

  7. 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?

  8. 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. ?

  9. 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.

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