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Medi-Cal Share of Cost

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					Medi-Cal Share of Cost




      Randolph T. Boyle
        Staff Attorney
California Medicare Coalition
           Webcast
        April 9, 2008
    What is a “Share of Cost (SOC)?”
   Spending down monthly income in
    order to qualify for Medi-Cal under the
    Medically Needy or Medically Indigent
    programs
   Similar to a deductible, but no
    insurance until it is met.
   Not like a premium--not a monthly
    debt to be paid
   County notice of action will show the
    amount of the SOC
    How is SOC determined?

Countable
Income – Medically Needy Level = SOC

First apply deductions and exemptions to income
   E.g. $20 any income disregard, payments for
   health care premiums
Medically Needy Income Levels (MNL, MNIL)
   have stayed the same since 1989
What is “meeting” a SOC?

   The beneficiary must incur that
    amount of medical expenses in the
    month before Medi-Cal will begin to
    pay.
   The SOC need not be paid, only
    incurred
   How and whether the medical
    expenses are paid for is between
    the beneficiary and the provider
How does someone meet the SOC?

   When a beneficiary uses the Medi-
    Cal card for medical services
       Only for current services
   Taking bills to the Medi-Cal
    eligibility worker at the county office
       May apply old bills to this month or a
        previous month’s SOC
    Using Old Bills to Satisfy a SOC

   Paid bills
       May only apply to the month in which they
        are incurred and paid
   Unpaid bills
       Must still be owed
       Must have a bill dated within 90 days
            May be a reissued bill
       Credit card statements—must show all of
        them since the debt first appeared
       Sworn statements
Whose bills can be used?

   The beneficiary’s medical expenses
   A dependent family member’s
    expenses
   Bills for services received before
    getting on Medi-Cal
      What kind of medical expenses can be
      used?

   Medi-Cal covered services
   Services that Medi-Cal would cover, but are
    beyond the amount, duration or scope of Medi-
    Cal.
   Services that Medi-Cal does not cover
   Cost sharing, such as from Medicare, and other
    health insurance premiums, deductibles, and
    co-payments
   When applying these to a person’s SOC, apply
    in the reverse order of what is listed above
How can someone avoid a SOC?

   Most Medi-Cal programs and most
    beneficiaries do not have a SOC
   Look at eligibility under another
    Medi-Cal program
       Aged & Disabled Federal Poverty Level
        (FPL) Program
       250% Working Disabled Program
       Pickles (people who lost SSI due to a
        COLA)
       Medi-Cal Waivers
    SOC and Managed Care
   Generally, people with only Medi-Cal
    with a SOC are not enrolled into a
    Medi-Cal managed care plan
       Except in County Organized Health
        System (COHS) counties
   Dual eligibles may enroll in Medicare
    Advantage plans or Special Needs
    Plans (SNPs)
       However, some SNPs will allow people to
        stay in the SNP when they do not meet
        their SOC while others will not
               Medi-Cal Share of Cost
                and Medicare Part D

   A Medi-Cal beneficiary with a SOC
    may receive the full LIS if:
       She meets her SOC in one month; or
       She completes an application for LIS and
        is approved for LIS.
        Meeting SOC and Getting LIS
   If the beneficiary meets her SOC once
    January-June:
       She gets the full LIS with the lowest co-payments
        for that month and the rest of the calendar year


   If the beneficiary meets her SOC once July-
    December
       She gets the full LIS with the lowest co-payments
        for that month and the rest of the calendar year
        AND all of the next calendar year
Questions?


Randy Boyle
Staff Attorney
National Health Law Program
(310) 204-6010, ext. 108
boyle@healthlaw.org
www.healthlaw.org
www.healthconsumer.org