MediCal:

Learning About the Nuances

July 2014

The following presentation is not for consumer use and is for

informational purposes for the 2014 Stronger Bridges to Health

Forum.

•MAGI Medi-Cal Review

•Non- MAGI Medi-Cal Programs

•Covered California Review & Processes

Revised 11/19/13

The California Medical Assistance Program, also

known as Medicaid, serves low-income families,

seniors, persons with disabilities, children in foster

care, pregnant women, and certain low-income

adults. It is jointly administered by the California

Department of Health Care Services (DHCS) and

the Centers for Medicare and Medicaid Services

(CMS), with many services implemented at the local

level mainly by the counties of California.

Traditional or “pre-2014” Medi-Cal, consisted of a large number of different programs. Although Medi-Cal programs usually provide the same level of medical coverage, applicants are evaluated for Medi-Cal programs based on the specific category they fall into.

Each Medi-Cal Program has it’s own eligibility criteria and rules.

Most Medi-Cal programs are free of cost. If an individual is not eligible for free Medi-Cal they’ll have what’s called a Share-of-Cost.

An individual is always placed in the lowest cost Medi-Cal program they are eligible for.

No coverage for Childless non-disabled adults 21-64 years

Effective 1/1/2014, some traditional Medi-Cal programs are “sunsetting”. Individuals who would have qualified for these programs will now have their eligibility determined in a new way. This new way of determining eligibility uses IRS/tax-based rules.

This new eligibility determination process is called the “MAGI” methodology.

MAGI stands for Modified Adjusted Gross Income

This new eligibility method will be considered MAGI Medi-Cal

Many Medi-Cal programs are not sunsetting. So even after 1/1/2014 while some individual’s eligibility will be based on MAGI rules other’s will continue to have their Medi-Cal eligibility based on traditional or Pre-ACA rules. This eligibility determination processes will be considered Non-MAGI Medi-Cal

Children (Under 19 years old)

Parents/Caretaker Relatives

Pregnant and Post-Partum Women

Former Foster Care

Adults 19-64 years old

› this is a new category of individuals who were not eligible under traditional Medi-Cal

rules

Individuals “deemed” eligible as a result of other

programs:

› SSI, CalWORKS, Foster Care, AA Program

Aged (65 or over), Blind or Disabled

Families (Parents living with children under 21)

Pregnant and post partum women

Adults with Medi-Care

Adults in Long Term Care

Individuals needing HCBS Waiver Services

SSI, CalWORKS, Foster Care, AA Program

MI/MN or MI/MN-Sneede

Pickle Program

Disabled Adult Child

A&D FPL Program

250% Working Disabled

Medicare Savings Program

Long Term Care Program

Home and Community Based Services

MAGI California Resident

No property test

Full and Restricted coverage (based on

citizenship)

Uses tax-based rules

› HH and Income

Eligibility Rules reside in Cal-HEERS

Eligibility starts 1/1/14

Non-MAGI California Resident

Property test (MC007)

Full and Restricted coverage (based on

citizenship)

Uses AFDC & SSI rules › HH, income & property

Eligibility Rules reside in CalWIN

Eligibility prior to 1/1/14

Doctor Visits

Hospital Care

Prescriptions Drugs (except if Part D eligible)

Pregnancy-Related Services

Eye Care*

Dental Care

Emergency Services

* Adults only receive routine eye care and exams

• All Medi-Cal applicants must be evaluated under MAGI Medi-Cal FIRST

• Simplified rules

• No asset test

• As of 1/21/2014 an automatic CalWIN-CalHEERS

interface went live

• Not all will qualify for Medi-Cal under MAGI rules

• Some groups of individuals, ineligible under MAGI rules may be evaluated for Non-MAGI Medi-Cal or covered California