Chapter 6 Share of Cost Rules
What is a Share of Cost?
If you are eligible for SSI/SSP except for excess
income or are on the Medi-Cal Medically Needy Program (ABD MN), and
qualify for IHSS you may have a share of cost (SOC). There is a Medi-Cal SOC and an IHSS SOC. You will only need to meet your IHSS SOC to
be eligible for IHSS services/Medi-Cal services. Non-payment of your SOC will cause you to
become ineligible for IHSS and Medi-Cal.
Medi-Cal Share of Cost
Medi-Cal SOC is the monthly
amount Medi-Cal requires you to pay each month, or requires you to agree to pay
in the future, for medical goods and services before Medi-Cal begins to
pay. You may meet your SOC by paying
for, or by agreeing to pay for, medical goods and services. You may meet your SOC by paying an old bill,
by presenting an old bill you are obligated to pay. You can meet your SOC by paying for or
agreeing to pay for services and equipment Medi- Cal
would not cover if Medi-Cal were paying.
is designed to be an income-maintenance program as well as a medical care
reimbursement program. It is designed to
pay for medical expenses so that beneficiaries can use the income that they
have for food, clothing and shelter. The
program does this by providing Medi-Cal without a SOC to individuals who
receive SSI/SSP or are on Medi-Cal Programs such as the Aged and Disabled
Federal Poverty Level Program, the 250% Working Disability Program, the Pickle
Program, or 16196.
monthly SOC for Medi-Cal is called
“Spenddown.” This is the amount a
beneficiary has to spend for medical care before Medi-Cal will begin to
pay. The term “spenddown” is also used
to describe spending down of excess countable resources ($2,000 for an
individual and $3,000 for a couple) in order to qualify for Medi-Cal. It is important not to confuse income
spenddown and resource spenddown.
might think that beneficiaries who have a SOC
for Medi-Cal would only have to spend down to the SSI/SSP
benefit level in order to obtain Medi-Cal coverage. After all, this would leave non-SSI/SSP recipients the same amount of money for food,
clothing and shelter that SSI/SSP
recipients have. However, Medi-Cal SOC does not work that way. Medi-Cal has a uniform method for determining
share of cost that is based on a percentage of the old AFDC amounts. This means that beneficiaries with a Medi-Cal
SOC have to spend down below the SSI/SSP
level before Medi-Cal will begin to pay for medical expenses.
amount that Medi-Cal beneficiaries with a SOC
have to spend down to is $600 per month for an individual and $934 for
couples. This is the MNIL or Medically
Needy Income Level. (For purposes of
this publication, we will ignore various exclusions and deductions from income
in order to simplify calculations.) The
SSI/SSP benefit level for 2007 for
an individual is $856 per month, which is $256 per month higher than the
MNIL. Therefore, a Medi-Cal beneficiary
with a SOC will have $256 less in
monthly income for food, clothing, shelter and other expenses than an SSI/SSP recipient, if the beneficiary meets his or her
Medi-Cal SOC for the month.
IHSS Share of Cost
IHSS recipients with a SOC, the State pays part of the share of cost so that
IHSS recipients pay down to the SSI/SSP
grant level rather than down to the lower MNIL of $600 under the ABD MN program
(this is called the “buy-out account”).
Before recent changes, the State would pay for part of the share of cost
only if you met your share of cost by paying your IHSS providers. That has
changed so that now you can pay (or incur an obligation to pay) for any needed
service including health plan premiums and services that may not be available
under Medi-Cal (like extra physical therapy). At the time the provider is to be
paid for the first half of the month, your records will be checked so that any
unused share of cost will be counted then. Both you and the provider will get a
notice about that month’s share of cost, if any. DSS
ACL 06-13; DHS ACL 05-21.
This process is explained more thoroughly below.
the example of a MNIL of $600 and an SSI/SSP
benefit amount of $856, the buy-out amount would be $256. If an individual on IHSS has countable income
of $1,200, the Medi-Cal SOC would be $580 ($1,200 - $20 allowable deduction-
$600 MNIL). The IHSS SOC would be $324 ($1,200
- $20 - $856). DSS pays DHCS $256 at the
beginning of the month towards the beneficiary’s Medi-Cal SOC and the recipient
is responsible for meeting the IHSS SOC of $324 and not the Medi-Cal SOC of
$580. Therefore, the buy-out amount is
designed to equalize the Medi-Cal and the IHSS SOC
by making an up-front payment of about $256 per month toward the Medi-Cal SOC.
order to implement the Buy-Out system, the CWD will send two eligibility
notices of action to the beneficiary.
One will be a Medi-Cal eligibility notice of action showing the Medi-Cal
SOC. The other will be an IHSS notice of action
showing the IHSS SOC. As an IHSS recipient, you will only be
responsible for the IHSS SOC.
New Share of Cost System
new SOC process is described in ACLs
05-35, and 06-13. The new system is more
complicated than the old system because share of cost for IHSS services for
recipients who also receive federally-funded Medi-Cal (PCSP and IPW) must be
combined with other Medi-Cal recognized expenses.
counties do this by using the IHSS computer system as a point-of-service (POS) system for inputting IHSS SOC information in
much the same way that a doctor or pharmacist providing Medi-Cal services
inputs Medi-Cal SOC information.
new system is mostly positive because:
1. Medi-Cal recognized expenses (MRE), in addition to
IHSS provider wages, can now be used to incur Medi-Cal SOC for IHSS recipients.
2. If other MRE (other than IHSS provider wages) are used
to meet SOC for Medi-Cal, the IHSS recipient can receive a full IHSS payment
notwithstanding the IHSS SOC.
the old IHSS SOC system, the IHSS SOC was calculated and deducted from the check to
the provider. The IHSS recipient was
then responsible for payment of the SOC
to the provider.
system is still in place, but it is more complicated because other Medi-Cal MRE
in addition to IHSS provider wages can now be used to reduce SOC.
Therefore, the SOC payable
to the provider may be less than the total IHSS SOC
but it will never be more.
way of putting this is that there is now only a single Medi-Cal SOC for PCSP and IPW beneficiaries rather than a
single IHSS SOC. Wages paid to the IHSS provider are a
Medi-Cal MRE the same as a payment to any other provider such as a pharmacist
or doctor. Therefore, wages paid to an
IHSS provider are added together with payments to doctors, pharmacists and
other Medi-Cal or non-Medi-Cal providers, for MRE, in order to determine if the
Medi-Cal SOC has been incurred
(paid or obligated). Once the total Medi-Cal
SOC has been incurred, the
beneficiary can receive Medi-Cal (and IHSS) with no SOC.
How the New SOC System Works
and terms you need to know:
(Medi-Cal Eligibility Data System)
(Medi-Cal Automated Eligibility Verification System)
way this unified Medi-Cal SOC
works is that all providers (except the IHSS providers) input SOC data into MEDS to show that SOC has been paid or obligated. Ordinarily, a provider will swipe the
Medi-Cal beneficiary’s BIC card in order to look up SOC
data on a system called AEVS. This
system tells the Medi-Cal provider how much the total SOC
is, and how much of the SOC has
not yet been paid or obligated (remaining SOC). The Medi-Cal provider then knows whether to
bill the beneficiary or bill Medi-Cal for the service. If the Medi-Cal provider bills the
beneficiary, the amount billed is input and shows up in MEDS
as part of the incurred SOC.
a Medi-Cal beneficiary receives MRE from a non-Medi-Cal provider, or receives
MRE that are not reimbursable by Medi-Cal, the beneficiary must take receipts
to the County Welfare Department (CWD) Medi-Cal eligibility worker and have the
information entered into MEDS. This part of the process has not changed.
the CWD cannot swipe the BIC card in order to determine how much SOC remains and must therefore be paid by the IHSS
recipient to the IHSS provider. Instead,
the CWD looks up the remaining SOC
in the MEDS system when processing
the timesheet. This remaining SOC is then deducted from the check to the provider
instead of the full IHSS SOC, as
was done under the old system.
under the new system, the SOC
deducted from the check to the provider can be less than the full IHSS SOC depending on what the MEDS
system shows. If the IHSS recipient has
not paid or obligated any SOC, the
deduction from the provider check will be the full amount of the SOC (prorated because of two monthly IHSS
payments). If the IHSS recipient has
paid or obligated SOC for MRE, the
SOC deduction from the check will be
the remaining SOC.
the CWD determines the actual IHSS SOC
and deducts that amount from the check, the system generates two notices of
action. One notice is sent to the IHSS
provider telling the IHSS provider how much to collect from the IHSS recipient. The other notice is to the IHSS recipient
telling the IHSS recipient how much the IHSS recipient must pay directly to the
Potential Problems with New Share of
No Apparent Retroactive Processing of Buy-Out Amounts
main problem with this system is that there may be a delay in Medi-Cal provider
MRE information showing up in the MEDS
system. If the IHSS SOC is deducted from the paycheck before the other
MRE information shows up in the system, the beneficiary will have to pay more
than his or her Medi-Cal SOC for
both Medi-Cal MRE and IHSS services.
Apparently, there will be no retroactive SOC
adjustments to correct this. Buy-Out
information will be processed between the 24th and 28th
of the month. If there is a glitch in
the system so that the Buy-Out is not processed, the beneficiary will be
responsible for the entire Medi-Cal SOC
for the month.
No Proration of SOC Deductions among Multiple Providers’ Checks
the new system, the first timesheet processed will result in the SOC deduction from that provider’s check. If you have more than one provider, SOC will
not be prorated among the various provider checks.
Delays and Elimination of Direct Deposit In Advance Payment
the new system, advance pay with SOC
checks will be processed manually.
Processing must be done on or after the first of the month. Therefore, there will be a delay in receiving
the advance pay check. Direct deposit
will no longer be available for advance pay checks.
Possible Ways to Avoid a SOC
One thing to consider in all
of this is that Medi-Cal beneficiaries who qualify for the A&D FPL Medi-Cal
program will not have a SOC for
Medi-Cal. Individuals currently qualify
for the A&D FPL program if
they have countable incomes of less than approximately $1,081 per month. Therefore, only individuals with countable
incomes of more than $1,081 per month must spenddown to $600 per month in order
to qualify for Medi-Cal! For more
information about the A & D FPL program, go to: http://www.healthconsumer.org/cs029AgedDisabled.pdt
you have a SOC due to community deeming rules based on your spouse’s or
parents’ income if you are minor, you should see whether you can qualify for a
HCBS Waiver, such as the DD Waiver, under institutional deeming rules. Once you are eligible for participation in a
HCBS Waiver, you will automatically have zero share of cost.
If your earnings cause you to
have a SOC, you may wish to have your Medi-Cal program converted from the ABD
MN to the 250% Working Disabled Program (WDP).
The 250% WDP allows an individual to earn countable income up to 250% of
the federal poverty level while still maintaining eligibility for Medi-Cal
benefits. You will have a monthly
premium based on your income but it will be considerably less than your monthly
SOC if you remain in the ABD MN program.
For more information about the 250% WDP, please refer to: http://www.healthconsumer.org/cs032WorkingDisabled.pdf
Potential Problems with IHSS and Medi-Cal Co-Administration
and terms you need to know:
Case Management, Information, and Payrolling System)
(Statewide Client Index)
and the CWDs use the CMIPS computer system to administer the IHSS program,
including PCSP and IPW. CMIPS contains
IHSS eligibility information and payroll information. When a person first becomes eligible for IHSS
the CWD inputs the hours of need and provider information, and generates a
timesheet. When the timesheet is
returned after the close of the pay period (the 15th and 30th
of the month for non-advance pay recipients) the system generates a paycheck,
which is sent directly to the provider.
The paycheck arrives 10 days after the close of the pay period—the 25th
for pay periods ending on the 15th and the 10th for pay
periods ending on the 30th.
The paycheck has a timesheet attached, which is then submitted at the
close of the current pay period. This
generates a paycheck with a new timesheet attached, and so on and so on and so
and CWDs use the MEDS system for
Medi-Cal eligibility. DHS also uses the MEDS computer system for Medi-Cal billing by
Medi-Cal providers, such as doctors and pharmacists. When a Medi-Cal beneficiary presents for
service, the doctor or pharmacist swipes the beneficiary’s Medi-Cal BIC card to
determine if the beneficiary has a share of cost for Medi-Cal, and, if so, how
much. If the beneficiary does not have a
share of cost, the provider bills Medi-Cal for the service. If the beneficiary has a share of cost, the
provider bills the beneficiary for the service and enters the billing
information into MEDS to show that
the beneficiary has paid or obligated some or all of his or her share of
cost. This transaction reduces the
beneficiary’s remaining share of cost.
that the CWD has to input IHSS SOC transactions into the MEDS system in much the same way that doctors and
pharmacists do, the CMIPS and MEDS
systems must interface and reconcile various transactions. This is done through the CALWIN system
(CalWORKs Information Network). The
CALWIN system is the case management system for the CalWORKs program. County
IHSS workers often are
not familiar with the CALWIN system and must learn it. This may cause problems with delays and
improper or incomplete data entry.
Potential Eligibility Delays Arising From Erroneous Data Entries
problem that can come up at the initial eligibility stages is an incorrect
interface between CMIPS and MEDS
caused by multiple entries into the system, incorrect date of birth or Social
Security number in one or both systems, and inaccuracies in other identifying
information. Counties are supposed to
minimize this kind of problem by pulling basic eligibility information into
both the CMIPS and MEDS systems
from something called the SCI
(Statewide Client Index). This is the
first type of problem that is likely to occur with the interface between CMIPS
and MEDS and is the first thing to
watch out for with newly-eligible IHSS recipients.
Potential Medi-Cal Eligibility/Share of Cost Problems Arising with New IHSS
Cases Pending Full-Scope Medi-Cal Eligibility
problem is that for all new IHSS cases, the individual will be input into the
CMIPS system as an IHSS-R recipient until the Medi-Cal eligibility information
is pulled into CMIPS. These individuals
should have state-only zero share of cost Medi-Cal as long as they are IHSS-R
recipients. However, the state does not
seem to be providing zero SOC
Medi-Cal to IHSS-R recipients, even though the state is legally required to do
so. This will result either in no
Medi-Cal for IHSS-R recipients, or a double SOC
for both Medi-Cal and IHSS until the individual is coded from IHSS-R to either
PCSP or IPW.
New System’s Use of Aid Codes May Not Accurately Identify Some Zero SOC
may need to know that Medi-Cal and IHSS use the following aid codes to identify
whether or not an individual has a share of cost for Medi-Cal and whether or not
the individual receives IHSS and, if so, under which IHSS program:
SSI recipients—no share of cost Aid
code 10—over age 65
SSI recipients—no share of cost
code 10—over age 65
code 20—individual with a disability
code 60—individual who is blind
IHSS recipients (secondary Medi-Cal aid
code 2L—IPW recipient
code 2M—PCSP recipient
code 2N—IHSS-R recipient
second set of aid codes identifies the IHSS program that the individual is
in. It is used together with another
Medi-Cal aid code such as one of the SSI recipient aid codes listed above, or
some other Medi-Cal aid code, which may include aid codes for the A&D FPL program, Pickle eligibility, Craig v. Bonta (SB87)
addition, the CMIPS system uses the following discontinued Medi-Cal aid codes
for IHSS tracking purposes only:
code 18—over age 65 and does not receive SSI Aid
code 28—individual with a disability and does not receive SSI
code 18—over age 65 and does not receive SSI
code 28—individual with a disability and does not receive SSI
code 68—individual who is blind and does not receive SSI
code 68—individual who is blind and does not receive SSI
are two problems with these discontinued aid codes: First, the use of one of these aid codes does
not mean that the IHSS recipient necessarily has a share of cost for Medi-Cal
or IHSS. For example, an individual who
has A&D FPL Medi-Cal does not
receive SSI but does not have a share of cost for Medi-Cal either. Second, these aid codes were used in the past
to provide zero share of cost Medi-Cal to IHSS-R recipients. If Medi-Cal has discontinued the use of those
aid codes for that purpose, then Medi-Cal is no longer providing zero share of
cost Medi-Cal to IHSS-R recipients, which is a violation of the law.