Medi-Cal Share of Cost

Medi-Cal Share of Cost Randolph T. Boyle Staff Attorney California Medicare Coalition Webcast April 9, 2008

What is a “Share of Cost (SOC)?” • Spending down monthly income in order to qualify for Medi-Cal under the Medically Needy or Medically Indigent programs • Similar to a deductible, but no insurance until it is met. • Not like a premium--not a monthly debt to be paid • County notice of action will show the amount of the SOC

How is SOC determined? Countable Income – Medically Needy Level = SOC First apply deductions and exemptions to income E.g. $20 any income disregard, payments for health care premiums Medically Needy Income Levels (MNL, MNIL) have stayed the same since 1989

What is “meeting” a SOC? • The beneficiary must incur that amount of medical expenses in the month before Medi-Cal will begin to pay. • The SOC need not be paid, only incurred • How and whether the medical expenses are paid for is between the beneficiary and the provider

How does someone meet the SOC? • When a beneficiary uses the Medi-Cal card for medical services • Only for current services • Taking bills to the Medi-Cal eligibility worker at the county office • May apply old bills to this month or a previous month’s SOC

Using Old Bills to Satisfy a SOC • Paid bills • May only apply to the month in which they are incurred and paid • Unpaid bills • Must still be owed • Must have a bill dated within 90 days • May be a reissued bill • Credit card statements—must show all of them since the debt first appeared • Sworn statements

Whose bills can be used? • The beneficiary’s medical expenses • A dependent family member’s expenses • Bills for services received before getting on Medi-Cal

What kind of medical expenses can be used? • Medi-Cal covered services • Services that Medi-Cal would cover, but are beyond the amount, duration or scope of Medi-Cal. • Services that Medi-Cal does not cover • Cost sharing, such as from Medicare, and other health insurance premiums, deductibles, and co-payments • When applying these to a person’s SOC, apply in the reverse order of what is listed above

How can someone avoid a SOC? • Most Medi-Cal programs and most beneficiaries do not have a SOC • Look at eligibility under another Medi-Cal program • Aged & Disabled Federal Poverty Level (FPL) Program • 250% Working Disabled Program • Pickles (people who lost SSI due to a COLA) • Medi-Cal Waivers

SOC and Managed Care • Generally, people with only Medi-Cal with a SOC are not enrolled into a Medi-Cal managed care plan • Except in County Organized Health System (COHS) counties • Dual eligibles may enroll in Medicare Advantage plans or Special Needs Plans (SNPs) • However, some SNPs will allow people to stay in the SNP when they do not meet their SOC while others will not

Medi-Cal Share of Cost and Medicare Part D • A Medi-Cal beneficiary with a SOC may receive the full LIS if: • She meets her SOC in one month; or • She completes an application for LIS and is approved for LIS.

Meeting SOC and Getting LIS • If the beneficiary meets her SOC once January-June: • She gets the full LIS with the lowest co-payments for that month and the rest of the calendar year • If the beneficiary meets her SOC once July-December • She gets the full LIS with the lowest co-payments for that month and the rest of the calendar year AND all of the next calendar year

Questions? Randy Boyle Staff Attorney National Health Law Program (310) 204-6010, ext. 108 boyle@healthlaw.org www.healthlaw.org www.healthconsumer.org

Medi-Cal Share of Cost