How Can I Use My Share of Cost to get More Services I Need?

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#5596.01

This publication tells you about Medi-Cal with a share-of-cost. You may have a share-of-cost when your income is over a certain amount. It means you have to spend a certain amount of money each month before Medi-Cal will pay for services. This publication tells you what kinds of things count towards a share-of-cost.

OVERVIEW

There are a number of different ways that seniors and persons with disabilities can be eligible for Medi-Cal. This publication will focus on individuals who get Medi-Cal under the Aged-Blind-Disabled Medically Needy (ABD-MN) program. Under the Medi-Cal ABD-MN program, individuals whose income is above a certain amount can get Medi-Cal with a share of cost (SOC). 

This publication will give information about how these individuals can use their SOC to purchase additional services they may need to remain in their own homes.  Please keep in mind that there are a number of other different ways in which people can receive Medi-Cal without a share of cost.1

How do I know what my SOC is?

An SOC is an amount that an individual must spend down each month before the Medi-Cal program will cover any services. Individuals can meet their SOC by paying for medical goods and services; by incurring medical expenses even if those bills have not been paid; or by presenting old medical bills to the county that the person is obligated to pay. 

When an individual meets her Medi-Cal SOC at any time during a month, she will Medi-Cal in that month.  In months when an individual does not meet her SOC, she will not get Medi-Cal. The Medi-Cal program will also pay an individual’s Medicare Part B premium, which is normally taken out of her Social Security check, in any month when an individual meets her SOC.

To determine eligibility under the ABD-MN Medi-Cal program, the county Medi-Cal office will add up the individual’s gross earned and unearned income. The county deducts $20 from all unearned income. For earned income, the county will deduct $65 and then divide the remaining amount in half. The county then adds the two amounts together.

Next, the county will deduct any medical, dental, or vision premiums. These calculations will result in a figure called the net countable income. If an individual income is above a certain threshold, the individual will have an SOC. The county will then deduct a maintenance need from the net countable income to determine the SOC. Currently, the maintenance need is $600 per month for one individual and $934 per month for a couple.

The maintenance need is the amount of money individuals are allowed to keep under Medi-Cal rules in the ABD-MN Medi-Cal program. Everything in excess of the maintenance need is the SOC, and must be spent down before Medi-Cal will begin to pay for medical expenses in that month.

For example, if a single individual’s gross income is $1925.00 of unearned income, the calculation will look like this:

$1,925.00 - $20 (unearned income deduction) = $1,905.00

$1,905.00 - $600 (maintenance need for one person) = $1,305.00

The SOC is $1,305.

How do I use my SOC to get more services?2

Individuals are permitted to use expenses which are “for necessary medical and remedial services that are recognized under State law but not included in the [Medi-Cal state] plan” to meet their SOC.3 The California Department of Health Care Services (DHCS) has issued guidance about this as All County Welfare Director’s Letter 15-02, available at http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/ACWDL2015/ACWDL15-02.pdf.

Out-of-pocket personal care services are an expense that can be used to meet an SOC. The personal care services must be prescribed by a physician, nurse case manager, assessed as part of the IHSS assessment of need (but not provided under the IHSS program), or be included in the beneficiary’s plan of care as necessary to prevent him/her from being moved to a long term care facility for essential treatment. The documentation must certify that the individual may remain safely in his/her home with the provision of the personal care services and/or any IHSS hours already assessed.4

The provider may be a family member. The provider may also be an IHSS provider who provides care beyond the hours paid for by the IHSS program. Personal care services used to meet the Medi-Cal SOC may exceed the maximum assessed hours for the IHSS program, as long as the need for the hours is documented. This may be a temporary increase needed by a beneficiary being discharged from a hospital who wishes to avoid a nursing home stay, or the extended hours may prove necessary on a more consistent basis to avoid nursing home stays when a beneficiary’s care needs increase.

Example 1 (IHSS—Unmet Need):

Ms. A has been assessed by the county to need 350 hours of personal care per month.  The county IHSS program will pay for a maximum of 283 hours per month. This means the county has assessed Ms. A as having an unmet need of 67 hours. Ms. A can use her SOC to pay for the additional 67 hours she has been determined to need. If she meets her SOC by paying for additional care hours, she will have Medi-Cal and Medi-Cal will pay for the approved IHSS hours.

Example 2 (IHSS—Adult Companion Care):

Ms. A has been allotted 150 hours per month of IHSS. However, Ms. A has a need for around-the-clock attendant care5, including a need for someone to provide non-medical care, supervision, and socialization (Adult Companion Care). Although the IHSS program is a time per task program, Ms. A can use her SOC for to pay for Adult Companion Care.6 Ms. A will need to ask her doctor for a letter explaining Adult Companion Care is a necessary medical and remedial service for her. 

Example 3 (Over-the-counter drugs and supplies): 

Ms. A has been prescribed an over-the-counter medication by her doctor which Medi-Cal does not cover. She also needs additional incontinence supplies, beyond what Medi-Cal will authorize.  She can use her SOC to pay for the medication as long as it was prescribed by her doctor as necessary to treat her medical condition.  She can use her SOC to pay for additional incontinence supplies. 

Example 4 (Additional Nursing Facility Waiver Services):

Ms. A receives attendant care services through the Nursing Facility Acute Hospital (NF/AH) waiver at the NF-B level of care, meaning she has a budget of $48,180 per year, which she uses to receive approximately 12 hours of day of attendant care.  She needs more assistance however.  Ms. A can use her SOC for to pay for Adult Companion Care. Ms. A will need to ask her doctor for a letter explaining Adult Companion Care is a necessary medical and remedial service for her. 

Example 5 (Physical Therapy):

Ms. A’s doctor has determined that she needs ongoing physical therapy beyond what Medi-Cal or Medicare will cover.  Ms. A can use her SOC to pay for therapy services provided at a hospital or rehabilitation hospital outpatient clinic. Ms. A will need to ask her doctor for a letter explaining that physical therapy is a necessary medical and remedial service for her.

Example 6 (Nursing Facility):

See DRC publication on using your SOC if you are a nursing facility resident:  Using Your Medi-Cal Share of Cost if You are a Nursing Facility Resident

 

1 For more information about different programs you can consider (such as the A&D FPL, 250% working disabled, and Expansion Medi-Cal programs among others) see the following resources:
http://wclp.org/advocate-resources/manuals-2/2016-health-care-guide/
http://www.canhr.org/factsheets/medi-cal_fs/html/fs_ADFPLP.htm
http://www.healthconsumer.org/Medi-CalOverview2008Ch2.pdf
http://www.healthconsumer.org/New_Health_Law_CA_IssueBrief_2_Final.pdf
http://www.disabilityrightsca.org/pubs/PublicationsHealthBenefits.htm
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2 For information about using your SOC in a Nursing Facility, please see our forthcoming publication 5597.01 – (Return to main document)

3 42 CFR § 435.831(e)(2). – (Return to main document)

4 All County Welfare Directors Letter No.: 15-02, January 12, 2015. http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/ACWDL2015/ACWDL15-02.pdf – (Return to main document)

5 All County Welfare Directors Letter No.: 15-02, January 12, 2015. http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/ACWDL2015/ACWDL15-02.pdf  See also All County Welfare Directors Letter No. 90-11, implementing Hunt v. Kizer; – (Return to main document)

6 This is because Adult companion care is included as part of Waiver Personal Care Services (WPCS). WPCS are part of the Nursing Facility Home and Community-Based Services Waiver (NF/AH) administered by DHCS’ In-Home Operations Welfare & Institutions Code Section 14132(t), 14132.97. – (Return to main document)