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

CHCF explanation

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

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

Too much Income for Medi-Cal?

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

    • 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

  1. 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?

  2. 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. ?

  3. 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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