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Aged & Disabled Medi-Cal Program
Medi-Cal is California’s health insurance program for low-income or low-resource individuals, funded jointly through state and federal dollars. There are many different Medi-Cal programs, and each program has distinct eligibility criteria. The programs described below are designed for elderly or disabled individuals living at home or in community-based settings, like assisted living facilities. This information is not applicable to individuals in Skilled Nursing Facilities (SNFs) seeking Medi-Cal for long term care. For information on Skilled Nursing Facility Medi-Cal, please see: www.canhr.org/publications/PDFs/
Aged and Disabled Federal Poverty Level Program (A&D FPL)
The Aged and Disabled Federal Poverty Level Program (A&D FPL) serves individuals aged 65 and older, and persons with disabilities. The program makes full-scope Medi–Cal (i.e., health coverage for medically necessary services such as physician visits, hospital care, ambulances, prescription drugs, and in-home care ) available with no Share of Cost (SOC). To qualify for this program, individuals must meet all of the following three criteria:
Example 1: Single Applicant, Unearned Income
MARTHA IS SINGLE. She receives a pension of $250 per month and $975 from Social Security before premiums are withheld for Medicare. Her gross monthly income is $1,225. She pays $134 per month for a Medicare Part B premium.
Martha is eligible for Medi–Cal at no Share of Cost through the A&D FPL program, because her countable monthly income is below the $1,271 eligibility threshold.
Example 2: Married Applicants, Earned and Unearned Income
SAM AND ROSE ARE MARRIED, and both of them are applying to Medi-Cal. They receive a combined $1,400 in Social Security (unearned income) every month, so their countable unearned income is 1,380 ($1,400 - $20 [unearned income deduction] = $1,380). Sam also earns an additional $800 through his employment.
Sam and Rose are not eligible for Medi-Cal with no Share of Cost under the A&D FPL program, because their countable monthly income is over the $1,720 threshold for a couple. However, Sam and Rose could purchase an additional health insurance premium, such as dental or vision coverage, to reduce their countable income to below the $1,720 limit. Can purchasing private health coverage jeopardize Medi-Cal benefits?
Enrolling in a private health plan will not put you at risk for becoming ineligible for A&D FPL Medi-Cal. In fact, the cost of premiums may even help reduce your countable monthly income, bringing you below the income eligibility threshold. With private health coverage, you may also be able to access providers and services that would not be available to you otherwise. Under these circumstances, the private health coverage is billed first. Medi–Cal pays for the services it covers after the private health carrier pays or denies a claim.
What if there are Family Members not Applying to Medi-Cal?
If there are other family members, such as a spouse or dependents, living in the home who are not applying for Medi–Cal, a Maintenance Need Allowance (MNA) is also deducted from the monthly countable income. A big family needs a larger income, so it is logical that less of that income will be counted towards eligibility for A&D FPL.
Maintenance Need Allowance (MNA)
Example 3: Married Applicant, One Spouse Applying to Medi-Cal
JIM AND ELLEN ARE MARRIED. Ellen needs In-Home Supportive Services (IHSS) and is applying to Medi-Cal. Jim does not need Medi-Cal. Their combined income from Social Security is $2,100, before Medicare premiums are deducted.
Ellen is not eligible for A&D FPL, because her countable income is $75 over the $1,271 eligibility threshold. (The eligibility threshold for an individual is used when only one family member is applying). Again, Ellen could purchase a health insurance plan to reduce her countable income below $1,271.
What if my Family Members are Not Dependents?
Often, there may be an elderly couple living in the same household as a non-dependent adult child. If the elderly parents apply to Medi-Cal, the non-dependent adult children’s income is not counted. However, the applicant also may not make a Maintenance Need deduction for non-dependent adult children. See Example 4.
Example 4: Single Applicant Living with Non-Dependent Adult Children
MARTHA IS AN 87 YEAR OLD WIDOW. Due to declining health, she moved into her adult daughter’s home, where the daughter’s husband also lives. Martha earns $1,080 from Social Security before Medicare premiums are deducted. Her daughter and son-in-law have a combined income of $6,500 per month – but this income is not counted by Medi-Cal when determining Martha’s eligibility.
$1,080 (Martha’s gross unearned income)
Martha’s countable income is under $1,271 and is therefore eligible for Medi-Cal with no Share of Cost.
What if my income is too high?
If your income is above the eligibility threshold for A&D FPL Medi-Cal after making all deductions, and you cannot purchase health insurance premiums to reduce your income below the limit, you still may be eligible for Medi-Cal with a Share of Cost under the Aged, Blind and Disabled - Medically Needy Program (ABD-MN).
Aged, Blind and Disabled – Medically Needy Program (ABD-MN)
The Aged, Blind and Disabled – Medically Needy Program (ABD-MN) makes Medi-Cal coverage available to individuals who are over 65 years old, or blind or disabled, with a monthly Share of Cost. If you are enrolled in ABD-MN, you must pay your monthly Share of Cost before Medi-Cal will kick in and pay for remaining medically necessary health care services for the rest of the month.
Eligibility criteria for ABD-MN is identical to that of the A&D FPL, except that your income can be higher, and you will have to pay a Share of Cost. The Share of Cost is determined as follows: Medi-Cal starts with your countable monthly income (see “countable monthly income” under the A&D FPL program) and deducts a Maintenance Need Allowance based on the number of family members in the household (spouse, dependents, and the applicant.) The remainder is what you will owe as Share of Cost. See example below.
Example 5: Single Applicant, Unearned Income Above A&D FPL Threshold
SAM IS SINGLE. He receives $1,750 in Social Security every month, before Medicare premiums are taken out.
$1,750 (unearned income)
Sam is not eligible for A&D FPL, as his countable monthly income is $325 over the allowable amount of $1,271. As a result, he will have a share of cost of $996.
$1,596 (countable monthly income)
This means that Sam will have to pay $996 out of pocket each month towards his medical costs, before Medi-Cal will cover medically necessary health care. For many on the ABD-MN program, the Share of Cost is prohibitively high. Those with a countable income slightly above $1,271 should consider improving their current coverage by purchasing additional health insurance, which will in turn reduce countable income. In Sam’s case, he can either pay a $996 SOC, or he can buy a health insurance premium(s) for $325 to bring his countable income at or below $1,271.
Can I work and still be eligible?
Yes. Both the A&D FPL program and ABD-MN are designed to allow the working disabled to keep a portion of their earned income out of the countable monthly income, thus allowing them to maintain eligibility in many cases. When calculating the countable monthly income, Medi–Cal subtracts $65 from the earned income and cuts the remainder in half before adding it to the unearned income, making it easier for the working disabled to stay below the eligibility income threshold.
If you are working and enrolled in Medi-Cal, you may also consider applying for Medi-Cal’s 250% Working Disabled Program.
250% Working Disabled Program (250% WDP)
The 250% Working and Disabled Program (250% WDP) provides Medi-Cal coverage at the cost of a low monthly premium for individuals who meet the Social Security definition of “disabled” and whose countable monthly income is below 250% of the Federal Poverty Level:
www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c00-16.pdf. The monthly premium amounts are based on your income level. Premium costs are generally less than the Share of Cost an individual would have to pay under the ABD-MN program.
Who is eligible?
If you meet the Social Security definition of “disabled” (without regard to the substantial gainful activity component of the definition) you may be eligible for this program. In other words, you must have a medical determination of a physical or mental impairment lasting or proposed to last for one year. This can be shown by demonstrating that you receive Social Security Disability Income (SSDI), OR Supplemental Security Income (SSI) based on disability.
In addition, you must also be working, with countable monthly income under 250% of the Federal Poverty Level (FPL). Proof of employment and earnings must be provided. There is no minimum work requirement -- you can work for two hours a month and still be eligible.Temporary unemployment periods are also acceptable (26 weeks during the Medi-Cal annual eligibility time period). Disability income is excluded from countable income (see below.)
Your countable assets must be below $2,000 for an individual or $3,000 for a couple. Generally, countable assets are determined using the SSI asset rules. However, the 250% Working Disabled Program has special asset exemptions. Individual Retirement Accounts (IRAs) and other retirement plans are not counted as an asset, whether or not you are receiving periodic payments from the accounts. Additionally, you can save your income from work without it counting as an asset, so long as it is in a separate account that is not commingled with other assets.
Finally, to be eligible for the 250% Working Disabled Program your unearned income and resources must meet the eligibility requirements of the SSI/SSP program (except for the special asset and income exemptions described above.) However, neither prior nor current receipt of SSI/SSP is required.
Countable income limits
The countable monthly income limit for an individual is $2,530 and $3,430 for a couple. (See chart below.) Countable monthly income is determined by taking gross monthly income, and making the following deductions:
Monthly Premium Costs Based on Countable Income:
Monthly premium costs are due for payment on the 10th day of each month. Payments can be mailed in to the Department of Health Care Services or submitted electronically online at www.paycalifornia.com. Failure to make two consecutive monthly premium payments may result in disenrollment from the 250% WDP program.
Example 5: Single Applicant, Earned Income plus SSDI
CAROL IS 55 YEARS OLD AND SINGLE. She receives $1,700 in Social Security Disability Income benefits each month. She also works, watching her neighbor’s dogs while he is at work. She receives $50 as work income each month. Her total monthly income is $1,750.
$1750 (monthly income)
Carol is eligible for the 250% WDP Program with a $20 monthly premium cost.
To apply for the Aged and Disabled Federal Poverty Level Program (A&D FPL), Aged, Blind and Disabled – Medically Needy Program (ABD-MN) or the 250% Working Disabled Program (250% WDP), you may apply:
22 CCR 51301–51365; DHCS Essential Health Benefits: www.dhcs.ca.gov/services/medi-cal/Pages/Benefits_services.aspx#top
WIC 14005.40; ACWDL 00-57 www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/00-57.pdf
22 CCR 50223; 22 CCR 50167; ACWDL 11-11 www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c11-11.pdf
WIC 14007.9(a)(1)(A); ACWDL 00-16 www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c00-16.pdf
WIC 14007.9(b)(4); ACWDL 11-38 www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c11-38.pdf
ACWDL 00-16 www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/c00-16.pdf; 20 CFR 416.1124; 20 CFR 416.1112
Page Last Modified: August 13, 2019