How much does a person have to pay for services while on Medi-Cal?
The county looks at the applicant’s income after he or she establishes eligibility for Medi-Cal by spending down assets to no more than $89,280 for a couple with one spouse institutionalized or $2,000 for a single individual. The county looks at the income the individual receives in his or her own name and divides in half the income received in the name of both spouses. Of the income that counts as the income of the applicant, all (less $35) of the applicant’s income is considered his or her “share of cost” for Medi-Cal. This works like a regular health insurance deductible. The applicant pays or obligates him or herself to pay that much each month on medical expenses before Medi-Cal pays the remainder of Medi-Cal covered services.
For example, a single individual in a skilled nursing facility has an income of $1,000 per month. This person is allowed to retain $35 per month for personal needs. The remainder ($965) of the countable income goes toward his or her share of cost each month. Medi-Cal pays the remainder of the expenses for the month up to the Medi-Cal reimbursement rate that is negotiated with the facility. The law precludes the facility from “balance billing” or charging the individual or family for any more than the share of cost.
In the case of an institutionalized spouse with a well spouse in the community, the institutionalized spouse is allowed to allocate some of his/her income to the community spouse as long as the community
spouse’s income is below a certain level. For the year 2002, that amount is $2,232. If the community spouse’s income is over that amount, the community spouse retains all of his/her income. Here is an example of a couple with one spouse in a nursing facility and one spouse in the community:
Institutionalized Spouse $1500 Social Security
$400 Pension
$1900 Total
Spouse $600 Social Security
In this case, the institutionalized spouse is allowed to allocate $1,632 each month to his or her spouse ($2,232 -$600 = $1,632). The remainder, in excess of the $35 the institutionalized spouse is allowed to retain for personal needs, goes toward the share of cost each month. Medi-Cal pays the remainder of his or her medical expenses ($1,900 – $1,632 spousal allocation = $268 – $35 = $233 share of cost).