Medi-cal (called Medicaid in other states) is a program that helps low income persons and others with limited resources and high medical expenses.

Medi-Cal is different from Medicare Insurance. It is a needs-based program, and eligibility is based on the amount of income and resource a person has.

You should be aware that Medicare does not pay for all medical expenses, and usually must be supplemented with private insurance. Furthermore, there is no Medicare coverage for nursing home care beyond 100 days in any single benefit period. It also only pays for “skilled nursing care,” and therefore does not cover any “custodial care” expenses.

Also, it should be noted that there are a number of other Medi-Cal programs for special categories of consumers. This post focuses on Medi-Cal for long-term care.

Eligibility

To be eligible for Medi-Cal’s long-term care services, you must meet the requirements for: (a) income, (b) assets (real or personal property), (c) residence, and (d) citizenship.

Most of the eligibility requirements relevant to long-term care can be grouped into two general categories:

(1) those classified as categorically needy and therefore qualify for Medi-Cal;

(2) those who are medically needy and may become eligible by incurring medical expenses each month.

These categories include some low-income Medicare beneficiaries who are also eligible for Medi-Cal.

Low income individuals who receive cash assistance from programs like CalWORKS or Supplemental Security Income (SSI) qualify for Medi-Cal automatically. Other eligible groups are those who meet financial criteria but are not receiving cash assistance, including those with specific health needs like dialysis; individuals who are in a long-term care institution; or individuals who would require the level of care provided in a nursing home.

Individuals who are medically needy are those with high medical expenses who may have too much income or property to qualify as categorically needy. However, they must meet the cash assistance requirements (e.g., age, blindness, disability) to be eligible. These individuals may be eligible with or without a “share of cost.” This refers to the amount of medical expenses an individual must incur before Medi-Cal kicks in. Share of cost is determined by income.

Once you pay your monthly share of cost towards your medical expenses, you will receive a Medi-Cal card, which you can then use to pay for Medi-Cal covered services. Share of cost works like an insurance deductible. It is determined by the Medi-Cal Office and is generally defined as the difference between your gross monthly income, minus deductions and the need standard.