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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

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medi cal share of cost

Medi-Cal Share of Cost

Randolph T. Boyle

Staff Attorney

California Medicare Coalition

Webcast

April 9, 2008

what is a share of cost soc
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
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
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
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
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
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
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
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
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
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
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
Questions?

Randy Boyle

Staff Attorney

National Health Law Program

(310) 204-6010, ext. 108

[email protected]

www.healthlaw.org

www.healthconsumer.org

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