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Medi-Cal Details



Medi-Cal is the state-funded medical assistance program for low-income, uninsured children and families, and individuals who are entitled to a government health plan. Persons who receive SSI and TANF benefits automatically qualify for Medi-Cal due to their low-income and/or disabled status. In California, low-income individuals who do not have children cannot receive Medi-Cal, regardless of their life situation or income level.

Medi-Cal covers a variety of health care services, with programs designed for specific needs, including Breast and Cervical Cancer Treatment and Long Term Care. Individuals and families can receive care from a variety of health care professionals throughout the state of California for little or no cost. Covered care includes preventive care, hospitalization, doctor’s office visits, outpatient services, and more. Pregnant women also have tremendous coverage from prenatal care to delivery and 60 days of postnatal coverage through the Medi-Cal program.

Medi-Cal also provides coverage for refugees, confidential family planning (all ages), former foster children, Medical Support Enforcement, and extra services through the Child Health and Disability Prevention (CHDP) and Early and Periodic Screening Diagnosis and Treatment (EPDST) programs. Disabled individuals who qualify for Medi-Cal must have severe a physical and/or mental health condition that will last for at least one year and prohibit them from working, or potentially cause death. There is also a waiver program for disabled persons who wish to go back to work and still receive benefits.

 

Medi-Cal Eligibility Guidelines

In general, Medi-Cal is offered to persons who are U.S. citizens or legal residents (unless you are a refugee or asylee), and live in California. Depending on which eligibility group you fall under, your income must correspond will have to be less than or equal to the stated amount of federal poverty (FPL) for your group and family size. Your health is not a consideration for eligibility, with the exception of disabled persons and pregnant women. Anyone with a condition may qualify as long as they meet the income limits. Those who do not have full citizenship are eligible for emergency services including labor.

Income Limits

Pregnant Women & Infants 200%

Family of 1: $1,862 monthly, $22,340 yearly

Family of 2: $2,522 monthly, $30,260 yearly

Family of 3: $3,182 monthly, $38,180 yearly

Family of 4: $3,842 monthly, $46,100 yearly

Family of 5: $4,501 monthly, $54,020 yearly

 

Children Ages 1-5 133%

Family of 1: $1,238 monthly, $14,856 yearly

Family of 2: $1,639 monthly, $19,699 yearly

Family of 3: $2,068 monthly, $24,817 yearly

Family of 4: $2,497 monthly, $29,965 yearly

 

Children Ages 6-19 100%

Family of 1: $938 monthly, $11,170 yearly

Family of 2: $1,260 monthly, $15,130 yearly

Family of 3: $1,590 monthly, $19,090 yearly

Family of 4: $1,920 monthly, $23,050 yearly

 

Parent (unemployed) 100%

Family of 1: $938 monthly, $11,170 yearly

Family of 2: $1,260 monthly, $15,130 yearly

Family of 3: $1,590 monthly, $19,090 yearly

Family of 4: $1,920 monthly, $23,050 yearly

 

Parent (employed) 106%

Family of 1: $986 monthly, $11,840 yearly

Family of 2: $1,336 monthly, $16,038 yearly

Family of 3: $1,686 monthly, $20,235 yearly

Family of 4: $2,036 monthly, $24,433 yearly

 

Aged, Blind or Disabled 100%

Family of 1: $938 monthly, $11,170 yearly

Family of 2: $1,260 monthly, $15,130 yearly

 

Qualified Medicare Beneficiaries (QMB) 100%

Medicaid covers your premiums, coinsurance, and deductibles.

Single: $938 monthly, $11,170 yearly

Couple: $1,260 monthly, $15,130 yearly

 

Specified Low-Income Medicare Beneficiaries (SLMB) 120%

Medicaid covers your premiums only.

Single: $1,117 monthly, $13,404 yearly

Couple: $1,513 monthly, $18,156 yearly

 

Your Medi-Cal Card

As a  Medi-Cal member, you will receive a Benefits Identification Card (BIC) as soon as your are approved. Your card will cover a variety of medical and dental services through qualified Medi-Cal doctors, health care professionals, and facilities. Depending on the service, your coverage, and the provider, your card will indicate to the provider whether or not you must pay a copayment for your care. If your BIC was  never sent to you, if it was misplaced or stolen, or if the one you received has incorrect information, you can request a new one from your County Welfare Department.

 

Covered Services

Medi-Cal covers a variety of medical, dental, and vision services for their members, though it is necessary to contact your local health department for specific details on benefits. Locate and contact your nearest local county office for more information. Below are some examples of services covered when medically necessary under Medi-Cal.

    • Physician services
    • Preventive care
    • Prescription medications
    • EPSDT for members under 21
    • Eye exams and glasses
    • Physical, occupational and speech therapy
    • Mental health care
    • Diagnostic tests including MRIs
    • Chiropractic
    • Acupuncture
    • Medical transportation (ambulance and non-emergency)
    • Long term care services
    • Home health care
    • Wheelchair services
    • Hearing aids

Some services are not covered through Medi-Cal, and it is essential to check with your local welfare office or health department prior to obtaining a service. Medi-Cal may not cover your care or deny payment for various reasons, mostly depending on the individual’s coverage and the procedure they received. Contact Electronic Data Systems (EDS) at 916-636-1980 if you received a bill for a service that Medi-Cal did not pay for.

Medication coverage can be tricky with Medi-Cal, however, most are included with no copay. If your prescription is not covered, you can ask the pharmacy to send Medi-Cal a Treatment Authorization Request (TAR). In case of an emergency, a pharmacy can provide up to a 72 hour supply of medication before a TAR is received. Contact the Medi-Cal office for more information about TARs at 916-552-9100.

 

How to Apply

There are multiple ways to apply for Medi-Cal. You can start by visiting your nearest County Welfare Department to obtain a Medi-Cal application, or print your own and send it to your local office. You can also use the convenient online form at BenefitsCal. Upon application for Medi-Cal, you will receive a list of your rights and responsibilities and find out what is needed to complete the form. Include all required documents, such as proof of income, insurance information, residency, and anything else requested by the Medi-Cal form. Your application may take up to 45 day to process, and you can either hand it in personally or mail it to your County Welfare Department.

 

Resources

 

Medi-Cal

Apply for Benefits

Medi-Cal Contacts

County Welfare Departments

MEDI-CAL What It Means To You (PDF)

Medi-Cal Phone Support: 800-541-5555

Women, Infants and Children (WIC) program: 916-928-8500 or 800-852-5770.

 


 

 

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