Medi-Cal with a Share of Cost (SOC)
Medically Needy

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.

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 CHCFAB 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

Links & Resources 

California Code of Regulations

Chapter 2 – DETERMINATION OF MEDI-CAL ELIGIBILITY AND SHARE OF COST  

CHFC explanation of Share of Cost  

Federal Poverty Level &
Program Chart

Medi-Cal?  Covered CA Subsidies?  Enhanced Silver?
MAGI Income Chart

Ways to lower your #Share of Cost

Get a Medi Gap Policy

You can Avoid a Share of Cost  in the (ABD-MN) Aged, Blind and DisabledMedically Needy Program program  and then qualify for no-cost A&D FPL.  Just purchase Medi-Gap or other private health insurance product, including Part D Rxdental or vision insurance.  * Wikipedia * InvestopediaMerriam – Webster *

Get Quote for Medi Gap

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.

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

share of cost guaranteed issue medi gap

Visit our Medi Gap Guaranteed Issue Page

 

Dental For #Everyone,
has an excellent  website with full brochures, Instant online quoting and enrollment

Dental for everyone free quote

VSP Vision Enroll ONLINE

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 

Get FREE #Instant Individual & Family  California  Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Claus

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Takes all the complexity out of CFR §1.36B-3 *

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24 comments on “Share of Cost – Medically Needy – What is it?

  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:
    March 23, 2018 at 5:23 am

    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. Yes, Medicare.
    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?

  9. 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. ?

  10. 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?

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