Medi-Cal

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What is Medi-Cal?

Medi-Cal is California’s Medicaid health care program. This program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by federal and state taxes. You can apply for Medi-Cal benefits regardless of sex, race, religion, color, national origin, sexual orientation, marital status, age, disability, or veteran status. If you are found (or determined) eligible, you can continue to get Medi-Cal as long as you continue to meet the eligibility requirements.

Your local County Welfare/Social Services Department manages Medi-Cal eligibility determinations. If you have questions, you can find the addresses and telephone numbers under County Social Services Office Listing.

How Can Medi-Cal Help You?

Medi-Cal is a large program made up of many separate programs designed to assist Californians in various family and medical situations. When you apply for Medi-Cal, the information you provide on your Medi-Cal Application and any required verification will be used to determine which program(s) you qualify for, and which program is best for you and your family

People in many different situations qualify for Medi-Cal. They are listed below. If you are not in one of these groups, call your county social service agency to determine if you qualify for a county-operated medical assistance program.

You may automatically be eligible for Medi-Cal if you receive cash assistance under one of the following programs:

  • SSI/SSP (Supplemental Security Income/State Supplemental Program)
  • CalWORKs (California Work Opportunity and Responsibility to Kids). Previously called Aid to Families with Dependent Children (AFDC).
  • Refugee Assistance
  • Foster Care or Adoption Assistance Program.

Even if you don’t receive cash assistance, you may be eligible for Medi-Cal if you are one of the following:

  • 65 or older
  • Blind
  • Disabled
  • Under 21
  • Pregnant
  • Diagnosed with breast or cervical cancer
  • In a skilled nursing or intermediate care facility
  • Refugee status during a limited period of eligibility. Adult refugees may or may not be eligible depending upon how long they have been in the U.S.
  • Parent or caretaker relative of a child under 21 and
  • The child’s parent is deceased or doesn’t’t live with the child, or
  • The child’s parent is incapacitated, or
  • The child’s parent who is the primary wage earner is unemployed or underemployed.

Do I Have To Live In California To Get Medi-Cal?

Yes, you must be a resident of California to get Medi-Cal. A California resident is someone who lives here and plans to stay here, or someone who is working or looking for work in California.

How Do I Apply For Medi-Cal?
  • Call or visit your local county social services office and ask for a Medi-Cal application.
  • If you need help filling out the forms, call the county social services agency. Mail or take your application with the required verifications (proof) to the nearest social services agency in your county. If you don’t have all your verifications, or are not sure of what you need, please send what you have. You can send the rest later. The sooner the social services agency receives your application, the sooner your case may be processed and your Medi-Cal benefits can begin.
  • If you get SSI/SSP payments, your Social Security administration office automatically sets up Medi-Cal for you. No separate application for Medi-Cal is needed. You will get your Medi-Cal card (BIC) in the mail.
  • If you get CalWORKs payments, the county social services agency automatically sets up Medi-Cal for you. No separate Medi-Cal application is needed. You will get your Medi-Cal card (BIC) in the mail.
How Is my Medi-Cal Application Processed?
  • When the county receives your application, it will be given to an eligibility worker. The worker will review your application and determine if additional information is needed. The worker may ask you for information by mail or by phone. If you want to meet with your worker to discuss your application, call your worker to set up an appointment.
  • Once the eligibility worker has all of the necessary information, he or she will determine if you are eligible for Medi-Cal. You will get a letter in the mail telling you if your Medi-Cal application is approved or denied. If you do not understand this letter or do not agree with the information in this letter, contact the eligibility worker at the county social services agency. If you still disagree with the county’s action, you may file for a State Hearing by completing the back of the Notice of Action the county sends you or by calling the toll free number.
  • If your child(ren) is not eligible for free Medi-Cal, they may be able to get health coverage through the low-cost Healthy Families Program (HFP). Make sure you indicate on your application that we can send your information to the HFP if your child(ren) is found ineligible for free Medi-Cal.
  • Anyone can help you with the application process — a family member, friend, or anyone else of your choice.
How Long Does It Take to start using Medi-Cal?

Forty-five (45) days are allowed to process a Medi-Cal application not involving a disability. If you are applying for Medi-Cal based on a disability, your application process may take up to 60 days or longer depending on how quickly you complete the disability information and how quickly your doctors and hospitals submit your medical records. To avoid delays in the processing of your case, submit all information requested of you as soon as possible. Ask your eligibility worker for help if you are having trouble obtaining information. If you have an immediate medical need, such as pregnancy, indicate this need on your application and your application may be processed more quickly.

Do I Have To Pay For Medi-Cal?

It depends.

  • If your income is less than Medi-Cal limits for your family size, you will receive Medi-Cal services at no cost to you. (Refer to All County Welfare Directors Letter (ACWDL) 02-13 to view the Income Limit Chart.)
  • If your income is more than Medi-Cal limits for your family size, you will have to pay a certain amount only in the month you have medical expenses. The amount that you pay is called your share of cost (SOC). When you pay or promise to pay that amount, we say that you have met your SOC. Once you have met your SOC, Medi-Cal will pay the rest of your covered medical bills for that month. For example, if your SOC is $50, you must first pay or obligate (obtain your providers agreement to make payments on the SOC) $50. Your provider will enter the amount you paid or obligated into the Department’s database. Your case will certify when the amounts you paid or obligated equal the amount of your share of cost. Once your share of cost is certified; providers checking your eligibility will advised that you are eligible and covered services may now be billed to the Medi-Cal program. Please note, expenses incurred by ineligible members of your family may be used to meet the share of cost of eligible members.
  • If one spouse lives in a nursing home, Medi-Cal allows the spouse remaining in the home to keep all of the income he/she receives in his/her name regardless of the amount. If that amount is below $2,232 per month, then the spouse in the nursing home can give income to the spouse at home to bring the spouse at home up to $2,232 per month. Be sure to ask your county social service agency for an MC Information Notice 007 for more information on income.
SPECIFIC SITUATIONS
What If I’m Pregnant?

Many health care providers can offer you immediate, temporary, pregnancy related Medi-Cal services under a program called Presumptive Eligibility for Pregnant Women.

If you are pregnant or think you are pregnant, ask if your health care provider participates in this program. If you would like further information, please call 1(800) 824-0088 .

Is There A Special Program For Children and Pregnant Women Yes. Pregnant women and children may have more income and property than other people and still qualify for no-cost Medi-Cal services. The income guidelines are different for children under age 1, children 1 to 6, and children 6 to 19. Your family property, such as savings accounts or cars, is not used to determine eligibility if monthly income falls within certain limits.

What If I’m Disabled? If you feel you are disabled, make sure to note this on your application or let your eligibility worker know this when you mail in your application. There are certain criteria you must meet to receive Medi-Cal on the basis of disability. You must have severe physical and/or mental problem(s), which will last at least 12 months and keep you from working during these 12 months, or possibly result in death.

You must prove your disability. Proof may involve obtaining medical records, tests, and other medical findings.

For your child to receive Medi-Cal as a disabled child, he/she must have severe physical and/or mental problem(s) that prevent the child from doing daily activities that a healthy child does.

Disability is looked at in two different ways.

  • Presumptive Disability allows you to get Medi-Cal as a disabled person while waiting for a final determination of disability. Presumptive Disability covers only certain types of illnesses/diseases and conditions. Ask your eligibility worker if your special situation qualifies you for Presumptive Disability.
  • If your special situation is not covered under Presumptive Disability, it may take up to 60 days to determine if you meet the Medi-Cal definition of disability and can receive Medi-Cal as a disabled person.
Are There Special Treatment Programs?

Yes. There are programs to assist you if you need dialysis treatment or parenteral hyper alimentation (feeding tube) services.

Can a Person with Tuberculosis (TB) Get Medi-Cal?

Yes. If you are infected with tuberculosis and meet eligibility requirements, you may get limited outpatient tuberculosis medical services. Medi-Cal clinics and Medi-Cal providers who serve TB infected persons may assist you in applying for Medi-Cal. These providers may help you complete all initial Medi-Cal forms used in the application process and may gather applicant verification. This information will then be forwarded to the county welfare department (CWD) for a Medi-Cal determination. There are specific property and income limits for the TB program. The social services agency may need to contact you for additional information.

To be eligible for the TB program a person must:

  • Be infected with TB
  • Not be a Medi-Cal recipient whose coverage is mandated by federal laws;
  • Be a United State citizen or an alien with satisfactory immigration status according to Medi-Cal regulations;
  • Meet the income and resources requirements; or
  • Meet all other Medi-Cal requirements
Can I Get Help from Medi-Cal with Medicare Costs?

Yes. Medicare is different from Medi-Cal. Medicare is a federal health insurance program run by the Centers for Medicare and Medicaid Services. It is available to most people 65 years of age or older and certain disabled or blind persons, regardless of income. Medicare Part “A” covers hospitalization. Medicare Part “B” covers doctor bills.

If you receive Medicare, you may qualify for the following special Medi-Cal programs:

  • The Qualified Medicare Beneficiary program pays for the Medicare Part A and B premiums, co-insurance and deductibles. To be eligible you must have income at or below 100% of the Federal Poverty Level.
  • The Specified Low-Income Beneficiary and Qualifying Individual 1 program pays for the Medicare Part “B” premium. To be eligible you must have income below 135% of the Federal Poverty Level.
  • The Qualifying Individual 2 program reimburses you for a portion of your Medicare Part “B” premium that you have paid. To be eligible you must have income below 175% of the Federal Poverty Level.
  • The Qualified Disabled Working Individual program pays the Medicare Part “A” premium.

To be eligible you must have income at or below 200% of the Federal Poverty Level, be disabled, be employed and eligible under any other Medi-Cal program.

Even if you don’t qualify for the above assistance programs, your Medicare A and B premiums can be used as allowable deductions in the Medi-Cal share of costs calculation.

I am Disabled and Working: Can Medi-Cal Help Me?

Yes. The 250 Percent Working Disabled program allows you to buy into the Medi-Cal program by paying monthly premiums on a sliding scale based on your monthly income. Premiums range from a minimum of $20 to a maximum of $250 per month for an eligible individual, or from $30 to $375 for an eligible couple.

To be eligible for the 250 Percent Working Disabled program, you must:
  • Continue to meet the federal definition of disability as defined in federal law for Social Security disability programs, although you are able to work,
  • Pay a monthly premium based on net countable income, and

    Meet all other non-financial Medi-Cal eligibility requirements

    Are There Special Programs for Parents Who Lose Medi-Cal Because of Full-Time Employment or Receipt of Child Support Payments?

    Yes. Transitional Medi-Cal provides no costs Medi-Cal for up to 2 years for families who are no longer eligible for CalWORKs or Section 1931(b) Medi-Cal because of increased earnings from employment.

    Families who are no longer eligible for CalWORKs or Section 1931(b) Medi-Cal due to the collection or increased collection of child support payments may receive up to four months of no cost Medi-Cal.

    OTHER HEALTH CARE PROGRAMS

    What is the Healthy Families Program?

    Healthy Families Program is a low-cost health coverage program for children ages 0 through 19. A new program will be implemented in the near future that will allow the parents of these children to also participate in the Healthy Families Program. There are different health plans for different areas.

    Healthy Families Program offers:
    • Low-cost comprehensive health, dental and vision insurance
    • Choice of health, dental and vision insurance plans
    • Low monthly premiums from $4 per child to a maximum of $27per family.
    • No co-payment (a co-payment is the amount of money an insured or covered person must pay for some health care services or type of service) for preventive services (such as immunizations). $5 co-payment for non-preventive services (such as going to the doctor due to illness).
    • For children without health insurance and children with Medi-Cal with a share of cost.
    • Available for single or two-parent working families
    • Property (such as savings or cars) is not counted.

    To apply for this program, you may obtain a mail-in application by calling toll-free, 1 (888) 747-1222 . You can be referred to a trained Certified Application Assistant in your community to help you complete the application. You can also apply by marking “Yes” on Question 36 of your Medi-Cal application.

    What Is the Access for Infants and Mothers (AIM) Program

    The Access for Infants and Mothers (AIM) program provides health care to uninsured pregnant women whose income is too high to qualify for no-cost Medi-Cal.

    To qualify for AIM, you must be less than 30 weeks pregnant when you apply. AIM benefits include:
    • Prenatal visits
    • Hospital delivery
    • Full health care services during the pregnancy and for 60 days following the child’s birth.
    • Full health care services for the baby from birth to age two.
    For more information and an application, call 1 (800) 433-2611 .

    What is the Baby Cal?

    Baby Cal encourages pregnant women and their families to get early and ongoing prenatal care and to practice healthy behaviors throughout the pregnancy (no smoking, drinking or drugs).

    For information about Baby Cal call 1 (800) BABY-999 ( 1 (800) 222-9999 ) or click here.

    What is the Women, Infants and Children Supplement Nutritional Program (WIC)?

    The WIC program is for pregnant women, breast-feeding women, infants and children under five (5) years of age who have a medical/nutritional risk and are low-income. Due to limited federal funds, not everyone eligible for the WIC program will always receive services.

    The WIC program provides:
    • Coupons for food
    • Nutritional counseling
    • Nutrition education classes
    • Breast feeding help.

    For more information, call your local county health department, or look under “WIC” in the white pages of your phone book.

    What is the Family Planning Services Program?

    With Family Planning Services you will:
    • Receive information and education on your options for birth control
    • Discuss with your provider the birth control method that is best for you
    • Receive Family Planning Services at low or no cost.

    With Family Planning Services you can:
    • Receive continued follow-up care
    • Prevent unplanned pregnancies
    • Plan when to have your next child.

    Family Planning Services can give you:
    • Birth control supplies for men and women
    • Pregnancy tests
    • Breast and cervical cancer screening
    • Tests and treatment for sexually transmitted infections (STI)
    • Education, testing, and counseling for HIV, the virus known to cause AIDS.

    If you are low-income or are receiving Medi-Cal, Family Planning Services are available at no cost. You can get Family Planning Services from:
    • Your regular Medi-Cal health care plan, doctor, or community clinic.
    • Or, any other doctors or clinics that accept Medi-Cal.
    • Health care providers who participate in Family Planning, Access, Care and Treatment (PACT).

    For information about Family Planning Services, call 1 (800) 942-1054 .

    Are There County-Operated Health Care Programs?

    Yes. Individuals who are not eligible for Medi-Cal may qualify for a health care program offered by the county in which they live. Call your county social services office for more information.

    What is California Children Services (CCS)?

    California Children Services (CCS) financially assists low-income families who are unable to afford necessary medical care for children with serious medical problems. CCS arranges and pays for diagnostic evaluations, if required, without regard to the family’s income and resources. The CCS program covers almost all serious medical conditions that can be improved or stabilized, including:
    • Birth defects
    • Chronic illness
    • Genetic disease
    • Handicaps which are present at birth or develop later
    • Injuries due to accidents or violence.

    To apply for this program, contact your county health department.

    What is the Child Health and Disability Prevention (CHDP) Program?

    The Child Health and Disability Prevention (CHDP) Program is a health promotion and prevention program serving California’s infants, children, and teens. The CHDP Program provides periodic preventive health assessments to:
    • Children under age 21 with Medi-Cal < br />• Non-Medi-Cal eligible children from birth to age 19 with family incomes at or below 200 per cent of the Federal Income Guidelines and no source of health care coverage for preventive health care services
    • Children enrolled in Head Start and state preschool programs.

    Children identified with suspected problems after a health assessment are referred for necessary diagnosis and treatment. Many problems can be prevented, corrected, or reduced in severity by prompt diagnosis and treatment.

    Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) services are a benefit provided through the CHDP Program for Medi-Cal children not enrolled in a Medi-Cal managed care plans.

    For more information about obtaining services, or for help with getting an appointment and transportation, call the local CHDP program located in your county/city health department.

    What is In-Home Supportive Services?

    The In-Home Supportive Services (IHSS) program helps pay for services which enable individuals to remain safely in their own homes instead of entering a nursing home or board and care facility. To be eligible, you must be over 65 years of age, disabled, or blind. Disabled children are also eligible for IHSS.

    The types of services IHSS can help pay for include:
    • Housecleaning
    • Meal preparation
    • Laundry
    • Grocery shopping
    • Personal care services (such as bowel and bladder care, bathing, grooming and paramedical services)
    • Accompaniment to medical appointments
    • Protective supervision for the mentally impaired.

    To apply for IHSS, contact the local IHSS office at your county social services agency.

    Does Medi-Cal Offer Breast and Cervical Cancer Early Detection Programs?

    Yes. Finding breast or cervical cancer early improves the chances of successful treatment. Regular screening for these cancers is the best way to find the cancer early.

    Recommended Screening for Breast and Cervical Cancer:
    • Breast Cancer Screening—Beginning at age 40 it is recommended women get a breast examination and a mammogram every 1-2 years.
    • Cervical Cancer Screening—Beginning at age 18, women should get regular Pap tests. Individuals covered by Medi-Cal are encouraged to request screening from their health care provider.

    Can I Get Breast and Cervical Cancer Screening if I Don’t Get Medi-Cal?

    Yes. The California Cancer Detection Programs: Every Woman Counts provides free screening for breast and cervical cancer for uninsured women.
    To qualify for these free screening services, women must meet the following requirements:
    Be age 40 or older for breast cancer screening; 25 or older for cervical cancer screening
    Have no health insurance or have a high insurance deductible or co-payment
    Be lower income (at or below 200% of Federal poverty level)

    The Family Planning, access Care and Treatment (Family PACT) program also provides free breast and cervical cancer screening services.

    Call toll-free 1 (800) 511-2300 , Monday – Friday 9:00 AM – 7:00 PM, to find out if you qualify for these free screening services. We speak English, Spanish, Cantonese, Mandarin, Vietnamese and Korean. If you qualify, you will be referred to a health care provider in your neighborhood.

    What If I Need Breast Or Cervical Cancer Treatment?

    The Breast and Cervical Cancer Treatment Program (BCCTP) program may be able to help. BCCTP provides, at least, free cancer treatment for people who have breast or cervical cancer.

    To qualify for free care, you must:

    • Be screened by a BCEDP, BCCCP, or Family PACT provider; and
    • Found in need of breast or cervical cancer treatment.

    If you have full health insurance then your premiums, co-pays or deductibles must be over $750.

    To receive breast or cervical cancer treatment, you may be male or female, of any age and regardless of citizenship or immigration status. Some individuals may be eligible for full Medi-Cal benefits for the duration of their treatment if they meet federal requirements (female, under 65, no health coverage, diagnosed with breast or cervical cancer, and need treatment).

    For more information on this program or for the location of a qualified screening provider nearest you, please call 1 (800) 824-0088 . PROGRAM INFORMATION TELEPHONE NUMBERSFor General Information about Medi-Cal:

    • Call Electronic Data Systems Customer Service Unit at (916) 636-1980; or
    • Call your county social services agency office

    For Information About What Medical Services Medi-Cal Covers:

    • Call Your Provider (your doctor, dentist, clinic, hospital, etc.)
    • For Questions about Dental Services or Medi-Cal Dental Programs: 1 (800) 322-6384

    Prepaid Health Plans/Managed Care:

    • To Enroll/Disenroll Call MAXIMUS, the State’s Health Care Options Contractor: 1 (800) …
    • To File A “Plan Specific” Complaint Call your specific Health Plan
    • If You Are Not Satisfied, Call The State Office Of The Ombudsman: 1 (888) 452-8609

    Medi-Cal Billing Problems:

    • For Problems Or Questions Regarding Medical Bills, Call Electronic Data Systems: (9…

    Medi-Cal State Hearing:

    • To file a request for a Medi-Cal State Hearing: Call the Public Inquiry and Response Unit at 1 (800) 952-5253; For Hearing Impaired: TDD 1 (800) 952-8349Third Party Liability:

    • Health Insurance Billing and Coding, Premium Payment, Medicare Buy-in: 1 (800) 952-5294
    • Casualty, Personal Injury, Probate, Estate, Liens, Workers’ Compensation, Overpayment Recovery: 1 (800) 952-5294.

    Medi-Cal Beneficiary Fraud and Abuse: 1 (800) 822-6222
    Provider Fraud and Elder Abuse complaint line: 1 (800) 722-0432
    SSA or SSI/SSP Information: 1 (800) 772-1213
    (For hearing impaired: TTY 1 (800) 325-0778)

    Other Health Program Numbers:

    • For Healthy Families/Medi-Cal for Children application and/or information: 1 (888) 747-1222
    • Access for Infants and Mothers (AIM): 1 (800) 433-2611
    • Family Planning Services: 1 (800) 942-1054
    • Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program: 1 (800) 433-2611

    *Please note, this information is from the Medi-Cal website.
    The URL is: http://www.dhs.ca.gov/mcs/medi-calhome/FAQs2.htm#What%20is%20Medi-Cal?

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