Medi-Cal with a Share of Cost (SOC)
If your monthly income is higher than the limits to qualify for SSI or the A&D FPL program, but you meet the asset-level requirements, you may still be eligible for Medi-Cal with a share of cost (SOC).
SOC functions like a deductible. 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.
Your SOC is determined according to your monthly income, using the following 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.
Note: If you have Medi-Cal with a SOC, Medi-Cal will not pay your Medicare Part B 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 Copied from CA Health Care Advocates * Read the full article from CHCF
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
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Share of Cost Overview
Under share of cost Medi-Cal, beneficiaries must incur a predetermined amount of health care expenses each month (their “share of cost”) before Medi-Cal begins to offer assistance for that month. When the share of cost has been met, Medi-Cal will pay for any additional covered expenses for the month. Share of cost requirements apply only during months in which Medi-Cal’s assistance with health care expenses is needed. Beneficiaries pay their share of cost directly to the providers of health care services, not to the state.
Share of cost requirements are not the same as cost-sharing or co-pay requirements. Cost-sharing requires a recipient to pay a set amount or percentage of each health care service received, while “share of cost” requires recipients to take full responsibility for health care expenses up to a predetermined amount.
Share of cost Medi-Cal is typically used by beneficiaries in one of three ways:
1. Catastrophic coverage. Medical expenses for a major health event such as an injury or accident.
2. Long term care coverage. Support for nursing home care or in-home supportive services.
3. Coverage for costly chronic conditions. Health care services for an illness that is costly and/or chronic enough to generate high monthly medical expenses. Read the full article from CHCF *
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
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