Medi-Cal with a Share of Cost (SOC)
Explanation of 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.
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 CHCF * AB 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
Ways to lower your Share of Cost
Get a Medi Gap Policy
Avoid a Share of Cost of hundreds of dollars in the ABD-MN Aged, Blind and Disabled – Medically Needy Program program by aggressively using these exclusions and deductions so that they qualify for no-cost A&D FPL.
A helpful tip is for your client to buy a Medi-Gap or other private health insurance product, including dental or vision insurance.
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 MediCal 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.
Visit our Medi Gap Guaranteed Issue Page
Western Poverty Law - Exact Legal Rules on
Coverage for Low Income Californian's
Our Webpage on
References & Links
Health Consumer Alliance Fact Sheet
Disability Rights CA Share of Cost – Nursing Home Resident
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
Silver 94 vs Medi-Cal
Clarification from Fellow Agent Max Herr
Theoretically, a person could have income greater than > 100% and FPL, reject Medi-Cal and APTCs, but still be eligible to enroll in a Silver 94 health plan. If, at tax filing, their income actually was greater than > 138% FPL, by purchasing health insurance through CoveredCA, they would be eligible to receive the refundable tax credits because they would technically not be ELIGIBLE for Medi-Cal at that point.
PPACA says premium tax credits are “available” to qualifying taxpayers whose incomes are between 100% and 400% of FPL (no tax credits at all for persons who earn less than 100% FPL — of course that doesn’t make any sense either — but it prevents certain children from filing tax returns and collecting tax credits). Then the PPACA says you cannot have the credits if you are ELIGIBLE for any government-sponsored health plan (i.e., Medi-Cal, Medicare, Tri-Care, etc.). And, of course, no credits for persons who have an “offer” of affordable health insurance from their employer (or from their spouse’s/parent’s employer — does not apply to persons over age 19 or older unless carried as a dependent on mommy’s or daddy’s Form 1040).
Technically, the chart is accurate, (note that this explantion was written when the Covered CA chart showed 100 to 138% of FPL as eligible for Silver 94?) because it reiterates what the PPACA says, and what CoveredCA regulations permit (income > 138% and < 250% FPL = Silver CSR eligible). In actual practice, however, it’s a piece of crap — if a person is earning less than <138% FPL when they apply at CoveredCA, and ask for “help” paying their health insurance premiums, they are automatically swept into Medi-Cal (and, of course, children are eligible for Medi-Cal up to 266% FPL, although they can be opted out by checking NO to the “Does this person want help” box on the app — which we were never told last year). Wonder why we are now voter registration assisters?
So how does a person with income > 0% FPL and NOT qualify as eligible for Medi-Cal? One way is to be an illegal immigrant. But illegal immigrants can’t have tax credits either, so the chart is meaningless to them, too.
However . . . a person whose stated/estimated income at enrollment time is greater than > 138% and less than < 250% FPL would qualify for CSRs — Their income could change over the course of the year to less than < 138% FPL (i.e., unemployed, reduced hours, failure of their MLM venture, etc.) and they would immediately be eligible for Medi-Cal if they report the change, or they could stay on their CSR plan by choice and by paying the premium (but not change from Silver 73 or 87 to Silver 94 — they would automatically be swept into Medi-Cal instead). As long as their income is 100% FPL or more for the year, they will get the tax credits, which are “refundable” (the excess unused credits are payable to the taxpayer when they file their Form 1040). I don’t think the IRC/regulations disqualify a person from receiving the tax credits in a scenario such as this — the person could legitimately claim they had a reasonable expectation of returning to work, increased hours/pay, etc., and did not expect their income to remain in the eligibility range. I believe the “eligibility” criteria is assessed at enrollment application time.
People heard that they will lose their home if they are on Medi-Cal (i.e.,”asset recovery”) — which we know is not an entirely accurate statement, but whoever heard about asset recovery prior to 2014 unless their parents were in a nursing home and needed Medi-Cal to pay the cost?