Column 12 _ MediCal


I attended my first stage of training in Fresno and I am sorry to say I do not yet have all the answers I was hoping to find. It was frustrating to have a session where the presenter merely read slides to us for 8 hours.  Apparently she was an independent contractor just hired to present the materials, rather than an employee of Covered California.


The take home materials did teach us a bit more about the MediCal expansion.  Medi-Cal is California's version of the Medicaid program, paid for with federal and state taxes. This program provides health insurance to low-income California residents who meet certain requirements.  Also part of Medi-Cal is the Targeted Low-Income Children's Program (TLICP), formally known as Healthy Families. TLICP is a low-cost insurance program for children and teens that provides health, dental and vision coverage to children who do not have health insurance. Expanding eligibility for Medi-Cal is one way the Affordable Care Act is supposed to increase access to health insurance.  


In order to be eligible for Medi-Cal the applicant must reside, or intend to reside in California. Applicants will attest to their address on the single, streamlined application and the online application will accept that attestation as part of the verification process.  To be eligible for Medi-Cal the applicant must be a citizen, a national or lawfully present in the U.S. with acceptable immigration status.


The ACA modified the way California will be calculating household income for determining Medi-Cal eligibility. The new methodology is called Modified Adjusted Gross Income (MAGI). The federal law changed the Medi-Cal income test to a MAGI income test in order to align the eligibility rules for all new health insurance options that are available to individuals.

For each individual who is applying for coverage and who fits into one of the four MAGI eligibility groups (children, adults, parents & caretaker relatives, and pregnant women), there are three steps that must be taken to determine whether an applicant is eligible for Medi-Cal based on MAGI:


STEP ONE: Identify the members of the applicant's family who are considered part of his or her household for MAGI Medi-Cal purposes.

STEP TWO: Add the income of relevant household members of the applicant's household, applying the relevant income modifications.

STEP THREE: Compare total household income to the FPL (Federal Poverty Level) for the number of people in their household.  Note that this level is expanded under the ACA so more folks will likely qualify.




Applicants who are eligible for Medi-Cal may apply for health insurance at any point throughout the year. This is different than everyone else.  Others can only apply during Open Enrollment (10/1/2013 to 3/31/2014) or if there is a special event, such as loss of other coverage.  The effective dates for their Medi-Cal will be the date of the application. Some individuals may also be eligible to have Medi-Cal pay medical bills up to three months prior to the date of their Medi-Cal application. Everyone else will be effective the first of the month following the application date which generally must be received by the 15th of the month prior.

People who are eligible for Medi-Cal are not eligible for Covered California with premium assistance. However, when the online application determines that an applicant is not eligible for Medi-Cal, or at any point during the application process, the applicant can choose to request a full Medi-Cal determination by the California Department of Health Care Services on a basis other than MAGI(non-MAGI). In some instances, the coverage available on a non-MAGI basis might better fit an individual's health care needs.


While that is happening, the applicant can enroll temporarily in a Covered California Health Plan and use any premium assistance and cost-sharing reductions if their attested information qualifies them. It is important to know that if it turns out they are not eligible they must re-pay the premium amount up to a certain dollar amount. (The maximum premium amount is based on income is $600 for individuals with incomes below 200% of the FPL; $1500 for individuals with incomes between 200% and 300% of the FPL; and $2500 for individuals with incomes between 300% and 400% of the FPL.) If the Department of Health Care Services determines that the applicant is eligible for any Medi-Cal, then he or she would dis-enroll from the Covered California Health Plan and enroll in Medi-Cal.

I expect that most agents are going to feel it best to refer those that might be MediCal eligible to someone more expert in that process. 

Note: All information in this column is provided" to the best of my knowledge" subject to final regulation by the respective agencies.