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.

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

Ways to lower your Share of Cost

Get a Medi Gap Policy

Advocacy Tip:

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.

Get Quote for Medi Gap

Individual ACA/ObamaCare – NO SUBSIDIES!!! —  If you don’t have Medicare – Open Enrollment

Get Quote

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.

share of cost guaranteed issue medi gap

Visit our Medi Gap Guaranteed Issue Page  

 

Term Life Quotes

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Video on how much coverage for death protection you need

References & Links

CHCF explanation SOC Share of Cost Rev December 2017

My Medi Cal – 24 page brochure

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  

Too much Income for Medi-Cal?

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Guaranteed Issue - No Pre X Clause -
Quote & Subsidy Calculation for
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Silver 94 vs Medi-Cal

Historical Confusion

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?

 

Historical - Federal Poverty Level & Program Chart - Cost Sharing Reduction - Enhanced Silver at 100% of FPL is only theoretical
Historical – Federal Poverty Level & Program Chart – Cost Sharing Reduction – Enhanced Silver at 100% of FPL is only theoretical
Medi-Cal 100 to 138% FPL - Historical
Medi-Cal 100 to 138% FPL – Historical

 

 

18 comments on “Share of Cost – What is it?

  1. 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

  2. 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.

  3. 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

  4. 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.

  5. 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

  6. 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?

  7. 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. ?

  8. 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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