Worksheets for Determining Eligibility Under the Aged & Disabled Federal Poverty Level (A&D FPL) Medi-Cal Program

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#5450.01

This publication and the accompanying worksheets are to be used to determine if an individual, couple or an individual in a family qualify for the A&D Medi-Cal program. This is a no-share-of-cost Medi-Cal Program.

This publication and the accompanying worksheets may be used to determine if an individual, couple or an individual in a family may qualify for the ABD FPL Medi-Cal program. The ABD FPL program is a no-share-of-cost, full-scope Medi-Cal Program for people who are over the age of 65, or who have a disability. The worksheets are in the following order:

(A) Individual, (B) Couple, and (C) Individual with spouse and/or children

The income limits or ceilings listed in this publication for the ABD FPL program are : Individual $1,294, Couple $1,747 

Note: Most people who qualify for the ABD FPL Medi-Cal may also be eligible for some food stamps. If you are on food stamps – now called CalFresh – you get a plastic card to use like an ATM or debit card at the grocery. There are special rules and extra deductions to help seniors (60 and older) and persons with disabilities get food stamps. Call your county welfare department or talk to your County Medi-Cal or IHSS eligibility worker. You may also want to contact legal aid for help. Disability Rights California does not have expertise in food stamp eligibility.

What are the options if your countable income is too high to qualify for no-share-of-cost Medi-Cal under the ABD FPL Program?

Your “net countable income” is the income that is left over after allowable exclusions and deductions have been applied.  Allowable deductions include unearned & earned income deductions.

If your net countable income is higher than the income limit to qualify for the ABD FPL program, then you may have the option to:

  1. a) Qualify for the ABD FPL program, as a single individual, by purchasing additional supplemental health insurance 
  2. b) Qualify for the ABD FPL program, as a couple, by purchasing additional supplemental health insurance
  3. c) Qualify one spouse for the ABD FPL program while the other spouse applies for another Medi-Cal program
  4. d) Apply for the 250% Working Disabled Program

Also, your county must review your eligibility for all Medi-Cal programs that you may qualify for. This may include:

  1. e) Pickle Program
  2. f) Disabled Adult Child program
  3. g) Aged-Blind-Disabled (ABD) Medically Needy (MN) program

There are also other tools that the county can use to help you establish eligibility for Medi-Cal.  Some of these are:

  1. h) Long Term Care (LTC) Medi-Cal with a Community Spouse – Spousal Impoverishment Provisions
  2. i) Long Term Care (LTC) Medi-Cal with Parents or a Spouse – Home and Community Based Services (HCBS) Waivers
  3. j) Cafeteria Plan – Exempt income for working people with cafeteria plans

The rest of this publication will describe options (a) through (j) listed above in more detail. 

TIP: For help in finding insurance to help you qualify for the ABD FPL program, contact an insurance agent or your local “Health Insurance Counseling & Advocacy Programs (HICAP) at: https://cahealthadvocates.org/hicap/.  You have to tell HICAP how much you need to spend on insurance each month to qualify for the ABD FPL program; HICAP will not figure that out for you.

(a) Qualifying for the ABD FPL program, as a single individual

To qualify for the ABD FPL program, you can buy supplemental health insurance and pay a monthly premium, including: dental insurance, vision insurance, and Medigap insurance. The amount you pay out of pocket each month is deducted from your countable income before seeing whether you are eligible for the ABD FPL program.

Calculation – Single Individual

Here is how to determine how much you will need to pay in monthly insurance premiums to bring your countable income down low enough to qualify for the ABD FPL program.

Step 1

$1,342 (your gross income) – $20 (unearned income deduction) = $1,322 (countable income)

Step 2

$1,322 (countable income) - $1,294 (2020 ABD FPL single individual income limit) = $28 (net countable income/amount money you are over the income limit).

In this example, you must spend at least $28 to bring your net countable income low enough to qualify for the ABD FPL program. 

(b) Qualifying for the ABD FPL program, as a couple

Alice and Alberto are a married couple. Their combined monthly Social Security income before any Medicare deductions is $1,782.  They are not eligible for the ABD FPL program because their net countable income is above the ABD FPL couple income limit of $1,747. Their income is $15 too high.  If they paid $15 a month or more in supplemental health insurance – dental, vision, etc. – their countable income would be brought down to $1,747, which is under the ABD FPL program income limit for a couple.

Calculation - Couple

Here is how to determine how much a couple will need to pay in monthly health insurance premiums to bring their countable income below the ABD FPL program income limit.

Step 1

$1,782 (couple’s gross total income) - $20 (unearned income deduction) = $1,762

Step 2

$1,762 (countable income) - $1,747 (ABD FPL couple income limit) = $15 (net countable income/amount money couple is over the income limit).

In this example, the couple must spend at least $15 to bring their net countable income low enough to both qualify for the ABD FPL program. 

(c) Couples applying for two different Medi-Cal programs: one spouse applying for the ABD FPL program & the other spouse applying for another Medi-Cal program

If a couple is found eligible for the ABD FPL program they will both receive Medi-Cal under the ABD FPL program.  If they cannot qualify as a couple, they can apply for two different Medi-Cal programs. One spouse can apply for the ABD FPL program and the other spouse may apply for a different Medi-Cal program, such as the ABD MN program.  The Aged Blind Disabled Medically Needy (ABD MN) is a Medi-Cal Share of Cost (SOC) program.  Here is how to determine eligibility for a couple with one spouse under the ABD FPL program and the second spouse under the ABD MN.

Alice and Alberto are a married couple, who both have Medicare Part B, with a combined net countable income of $1,800.  Alberto is applying for the ABD FPL program because he has more health care needs than Alice.  Alice is applying for the ABD MN program.

If the spouse with more health care needs also needs or receives Home and Community Based Services (HCBS) services such as In-Home Supportive Services and/or HCBS waiver services see sections (h) and (i) below.

Calculations – One spouse in ABD FPL and one spouse in ABD MN program

Here is how Alberto’s eligibility for Medi-Cal under the ABD FPL program would be calculated under this program.  The Maintenance Need Level (MNL) used in the calculation below is the amount of money Medi-Cal allows individuals to live from.  Section (g), below, covering the ABD MN program will provide more information about the MNL.

Step 1 - Alberto

$1,800 (couple’s gross income) - $20 (unearned income deduction) = $1,780 (couple’s countable income)

Step 2

$1,780 (couple’s countable income)  - $600 (MNL for non-applicant spouse Alice) = $1,080 (Alberto’s countable income).

Note: The MNL is subtracted for Alice because Alice is not applying for the ABD FPL program.

Alberto’s income of $1,080 is below the $1,294 ABD FPL income limit for an individual; so, Alberto is eligible for Medi-Cal with no share of cost under the ABD FPL program. Next, we will calculate Alice’s eligibility for Medi-Cal under the ABD MN program.

Step 3 - Alice

$1,800 (couple’s gross income) - $20 (unearned income deduction) - $134 (Alice’s Medicare Part B) = $1,646 (couple’s countable income).

Note: Only Alice’s Part B Medicare premium is deducted because Alberto’s Medicare premium is paid for by Medi-Cal.

Step 4

$1,646 - $600 (MNL for Alice) = $1,046 (Alice’s Medi-Cal share of cost).

Note: the MNL is for a household of 1 is subtracted because Alice is the only spouse applying for the ABD MN program.

Result: Alice is eligible for Medi-Cal with a with a $1,046 SOC under the ABD MN program.  Alberto is eligible for Medi-Cal with no share of cost under the ABD FPL program.

(d) 250% Working Disabled Program

If you would like to test your ability to work, you may want to consider the 250% Working Disabled Program.  In many situations, this may lead to paying less out of pocket for Medi-Cal.  This is because the 250% Working Disabled Program is a no-share-of-cost, full-scope Medi-Cal program with monthly premiums as low as $20 per month.

Under the 250% Working Disabled Program, all disability-based income, such as Social Security Disability Income (SSDI), private disability pensions, etc., are not counted or are exempt.  To be eligible for the 250% Working Disabled Program, you have to show you would be eligible for SSI not counting exempt disability income and earnings. If you are receiving retirement including early retirement earnings above the SSI/SSP grant level, you do not qualify. 

TIP: For more information, click here for Health Consumer’s Medi-Cal Summary on the 250% Working Disabled Medi-Cal Program.

(e) Pickle Program

Did you (or your eligible spouse) ever qualify for SSI and Social Security at the same time? Social Security benefits include dependent benefits received by children. If so, you (and/or your eligible spouse) may be eligible for Medi-Cal with no share of cost under the Pickle Program.  For more information about the Pickle program eligibility you can review the National Health Law Program flyer entitled, A Quick and Easy Method for Screening for Medicaid Eligibility under the Pickle Amendment: 2020 Update.

(f) Disabled Adult Child program

The Disabled Adult Child (DAC) Medi-Cal program is for DAC Social Security recipients who lose their eligibility for Supplemental Security Income (SSI) benefits because of a cost of living increase in social security benefits or because the beneficiary became eligible for social security benefits.  If you believe you may be eligible for DAC benefits you can ask the county to process an application for Medi-Cal under the DAC program.

(g) Aged-Blind-Disabled (ABD) Medically Needy (MN) program 

The Aged-Blind-Disabled (ABD) Medically Needy (MN) program is a full-scope Medi-Cal program with a share-of-cost.  The share of cost is the countable income minus the applicable maintenance need level (MNL) based on family size – i.e., $600 for one person, $750 for an adult and child, $934 for a couple or three-person family, etc. 

For example, Alice and Alberto are a married couple. Their combined monthly Social Security income before Alberto’s Medicare deduction is $1,800 which after the $20 unearned income deduction equals a net countable income of $1,780. They are not eligible for the ABD FPL program because their net countable income is above the ABD FPL couple income limit of $1,747. However, they may be eligible for ABD MN program with a Medi-Cal share of cost of $578.

Calculation – Couple under ABD MN 

Here is how to determine how much a couple’s Medi-Cal SOC will be for the ABD MN program.

Step 1

$1,800 (gross income) - $20 (unearned income deduction) - $134 (Alice’s Medicare Part B premium) - $134 (Alberto’s Medicare Part B premium) = $1,512 (couple’s countable income)

Step 2

$1,512 - $934 (Maintenance Need Level or MNL for couple) = $578 (couple’s Medi-Cal share of cost).

TIP: For the ABD MN program you can also deduct out of-pocket healthcare costs not covered by your insurance to meet your Medi-Cal SOC each month.

(h) Long Term Care Services through Medi-Cal with a Community Spouse – Spousal Impoverishment

If you need LTC Medi-Cal but you have too much income to qualify for no-share of cost Medi-Cal programs and your spouse does not require LTC Medi-Cal / is a community spouse, then you may use “spousal impoverishment protections” to allocate your income to your community spouse in order to establish Medi-Cal eligibility without a share of cost.

Medi-Cal "spousal impoverishment protections" allows a Medi-Cal beneficiary's spouse who is not on LTC Medi-Cal to keep a couple's income and resources, up to what is called the community spouse resource allowance (i.e. resource limit) and the maximum spousal income allocation/minimum monthly maintenance needs allowance (i.e. income limit).  These special rules around income and resource limits go up every year based on cost of living increases.

In 2020, the community spouse’s Maximum Monthly Maintenance Needs Allowance (monthly income limit) is $3,216.00 and the community spouse’s Maximum Resource Standard (resource limit) is $128,640.00.  (All County Welfare Directors Letter No: 20-06).  This means that you can transfer some or all of your income to your spouse until your spouse’s income and resources combined with what you give to your spouse reaches the limits.

After you have transferred some or all of your income and/or resources to your spouse, up to the allowable monthly income limit and resource limits listed above, what is left over in income/resources will be used to determine your eligibility for Medi-Cal.

TIP: Based on SSI regulation 20 C.F.R. §416.1161(a)(16) applicable to Medi-Cal programs based on age or disability, IHSS income cannot be deemed to the spouse for purposes of determining the disabled spouse’s Medi-Cal eligibility.

Alice and Alberto are a married couple. Alberto needs Long Term Care services. Alberto receives these LTC Medi-Cal through In-Home Supportive Service Community First Choice Option (IHSS-CFCO), a Home and Community Based Supportive Service.  Alice has employer-based health insurance; so, she does not need Medi-Cal. Alberto is going to hire his wife to be his IHSS caregiver. Alberto receives a pension of $2,500 per month. Alice receives $700 per month in pension benefits. They also saved $80,000 for retirement in a savings account. They have no other income or resources.

Calculation for Income

Here is how to determine how much income Alice can keep so that Alberto can be eligible for Medi-Cal with no SOC under the ABD FPL program because Alberto has IHSS-CFCO.  Alice’s IHSS provider earnings will not count as stated above.

Step 1

Note: 2020 Maximum Monthly Maintenance Needs Allowance (maximum monthly income limit) is $3,216.00.  Alice’s income is a $700 pension.

$3,216.00 (max. monthly income limit for Alice) - $700 (Alice’s pension) = $2,516 (amount of money Alberto can allocate to Alice). Alberto can allocate a maximum of $2,516 to Alice.

Step 2

Alice keeps her $700 pension and Alberto allocates Alice all of his income ($2,500) each month for her.  Alice now has $3,200 each month to live from.

Step 3

Alberto has $0 income because he allocated all of his income ($2,500) to Alice. Alberto is eligible for Medi-Cal with no SOC under the ABD FPL program because his countable income ($0) is under the ABD FPL limit of $1294 for a household of 1.

Calculation for Resources

Here is how to determine how much resources Alice can keep so that Alberto can be eligible for Medi-Cal with no SOC under the ABD FPL program because Alberto has IHSS-CFCO.

Step 1

Note: The 2020 Maximum Resource Standard (resource limit) is $128,640.00.

Alice and Alberto have $80,000 (in resources) in savings.  $80,000 (savings) is less than $128,640.00 so Alice can keep all the savings.

Step 2

Alberto has $0 resources because he allocated the couple’s entire savings ($80,000) to Alice. Alberto is eligible for Medi-Cal with no SOC under the ABD FPL program because he has no resources ($0). Under the ABD FPL program the resource limit is $2,000 for a household of 1.

When Medi-Cal determines Alberto’s eligibility for Medi-Cal, it will count only his income and resources as a single individual.  Since Alberto has given his spouse all of his income and resources, he qualifies for zero share of cost Medi-Cal under the ABD FPL program.  This is because he has no income and no resources.

(i) Long Term Care (LTC) Medi-Cal services with Parents or a Spouse – HCBS Waivers

If an individual is ineligible for LTC Medi-Cal services with no share of cost because their spouse’ or parent’s income and/or resources are too high, then the person who needs LTC Medi-Cal may be able to qualify for Medi-Cal with no share of cost through one of the Home and Community Based Services waivers: 

ICF/DD Waiver:  If you are a client of a regional center serving persons with developmental disabilities, then you could qualify for services through an intermediate care facility for persons with developmental disabilities (ICF/DD) waiver.  You should talk to your service coordinator about qualifying for Medi-Cal through the waiver for persons with developmental disabilities.

HCBA Waiver:  If you are a senior or person with a disability who could qualify for care in a nursing facility, subacute nursing facility or a hospital, then you may consider applying for the Home and Community Based Alternatives (HCBA) waiver.  You can apply for HCBA waiver services by contacting the HCBA waiver agency that services the area where you live.  You can find contact information for the HCBA waiver agency assigned to your area online at: https://www.dhcs.ca.gov/services/ltc/Pages/Home-and-Community-Based-(HCB)-Alternatives-Waiver.aspx.   You can also call Medi-Cal at 1-833-388-4551or by email at: HCBAlternatives@dhcs.ca.gov.  There is no waiting list for people who need the waiver to get out of a nursing facility.

MSSP Waiver:  If you are a senior (65 and older) who would qualify for care in a nursing facility, call 1-800-510-2020 for information about whether the MSSP waiver is available where you live.  If the MSSP waiver is available then you may call then phone number to inquire about where and how to apply for the MSSP waiver.

(j) Cafeteria Plan -Exempt Income

If you have earned income, see if your employer has a cafeteria plan to pay for unreimbursed medical expenses.  Money put in a cafeteria plan does not count as income under Social Security and Medi-Cal rules because those funds are exempt from Social Security (FICA) withholding taxes.

Additional Medi-Cal Resources

You can visit our DRC Medi-Cal Self Advocacy Resources webpage for more information about Medi-Cal.

For Legal Assistance Call:

  • Call DRC’s intake line at: 1-800-776-5746.
  • Call DRC’s Office of Clients’ Rights Advocacy (OCRA) at:
    • Northern California 1-800-390-7032 (TTY 877-669-6023)
    • Southern California 1-866-833-6712 (TTY 877-669-6023)

You may also complete a request for assistance form: SHORT-TERM ASSISTANCE/INTAKE QUESTIONNAIRE.

 

 

Publication #5450 (pdf)

Publication #5450 - Worksheet for Individuals (pdf)

Publication #5450 - Worksheet for Couples (pdf)

Publication #5450 - Worksheet for Individual with a Spouse and/or Child (pdf)