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

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

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:

  1. Individual
  2. Couple
  3. Individual with spouse and/or children

The income limits or ceilings for the ABD FPL program are: Individual $1,482, Couple $2,004.1

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

What happens 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:

  1. Qualify for the ABD FPL program, as a single individual, by purchasing additional supplemental health insurance
  2. Qualify for the ABD FPL program, as a couple, by purchasing additional supplemental health insurance
  3. Qualify one spouse for the ABD FPL program while the other spouse applies for another Medi-Cal program
  4. 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. Pickle program
  2. Disabled Adult Child (DAC) program
  3. Aged-Blind-Disabled (ABD) Medically Needy (MN) program

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

  1. Long Term Care (LTC) Medi-Cal with a Community Spouse – Spousal Impoverishment Provisions
  2. Long Term Care (LTC) Medi-Cal with Parents or a Spouse – Home and Community Based Services (HCBS) Waivers
  3. 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.

(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 an example of how to determine how much you will need to pay in monthly health insurance premiums to bring your countable income down low enough to qualify for the ABD FPL program.

In this example, Mai lives by herself and is a household of one. Mai’s only income is $1,700 from Social Security Retirement.

Step 1

$1,700 (your gross unearned income) – $20 (unearned income deduction) – $148.50 (average 2021 Medicare Part B premium) = $1,531.50 (countable income)

Step 2

$1,531.50 (countable income) - $1,482 (2021 ADB FPL single individual income limit) = $49.50 (net countable income/amount money Mai is over the income limit).

In this example, Mai must spend at least $49.50 to bring her net countable income low enough to qualify for the ABD FPL program.

TIP: For help in finding insurance to help you qualify for the ABD FPL program, contact a healthcare 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.

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

To qualify for the ABD FPL program as a couple, you or your spouse can buy supplemental health insurance and pay a monthly premium. The amount you or your spouse pays out of pocket each month is deducted from the couple’s countable income before seeing whether you are both eligible for the ABD FPL program.

Calculation - Couple

Here is an example of how to determine how much you and your spouse will need to pay in monthly health insurance premiums to bring your countable incomes down low enough to qualify for the ABD FPL program.

Alice and Alberto are a married couple. Their combined monthly Social Security income before any Medicare deductions is $2,400.  They are not eligible for the ABD FPL program because their net countable income is above the ABD FPL couple income limit of $2,004. Their income is $79 too high.  If they paid $79 a month or more in supplemental health insurance – dental, vision, etc. – their countable income would be brought down to $2,004, which is under the ABD FPL program income limit for a couple.

Step 1

$2,400 (couple’s gross total income) - $20 (unearned income deduction) - $297 (couple’s Medicare premiums) = $2,083

Step 2

$2,083 (countable income) - $2,004 (ABD FPL couple income limit) = $79 (net countable income/amount money couple is over the income limit).

In this example, the couple must spend at least $79 to bring their net countable income low enough for both people to 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, then they will both receive Medi-Cal under the ABD FPL program. However, if both people cannot qualify as a couple, then one person can apply for the ABD PFL program and the other can apply for a different Medi-Cal program.2 For example, one spouse can apply for the ABD FPL program and the other spouse can apply for the Aged Blind Disabled Medically Needy (ABD MN) program.  Unlike the ABD FPL program, the ABD MN is a Medi-Cal program that requires the person to pay a Share of Cost (SOC) each month before Medi-Cal will pay.

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

Here is an example of 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 $2,200.  They are not both eligible for the ABD FPL program because their net countable income is above the ABD FPL couple income limit of $2,004. In this example, the couple does not want to purchase supplemental health insurance to bring their income under the ABD FPL program income limit for a couple.  In this example, 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. 

REMEMBER: The Maintenance Need Level (MNL) used in the calculation below is the amount of money Medi-Cal allows individuals to keep to pay for living expenses.  Section (g), below, covering the ABD MN program will provide more information about the MNL.

Step 1 – Alberto

$2,200 (couple’s gross income) - $20 (unearned income deduction) - $148.50 (Alberto’s Medicare premium) = $2,031.50 (couple’s countable income)

Step 2 – Alberto

$2,031.50 (couple’s countable income) - $600 (MNL for non-applicant spouse Alice) = $1,431.50 (Alberto’s countable income).

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

Alberto’s income of $1,431.50 is below the $1,482 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

$2,200 (couple’s gross income) - $20 (unearned income deduction) - $148.50 (Alice’s Medicare Part B) = $2,031.50 (couple’s countable income). 

REMEMBER: Only Alice’s Part B Medicare premium is deducted because Alberto’s Medicare premium was already deducted in his income calculation.

Step 4 – Alice

$2,031.50 (couple’s countable income from step 3) - $600 (MNL for Alice) = $1,431.50 (Alice’s Medi-Cal share of cost).

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

Alice is eligible for Medi-Cal with a $1,431.50 share of cost under the ABD MN program.  While, Alberto is eligible for Medi-Cal with no share of cost under the ABD FPL program.

TIP: 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.

(d) 250% Working Disabled Program

If you would like to test your ability to work, then 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 towards your income.  To be eligible for the 250% Working Disabled Program, you have to show you would be eligible for SSI when not counting disability-based income and earnings. If you are receiving retirement including early retirement earnings above the SSI/SSP grant level, you may 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?3 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: 2021 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. For more information about the Disabled Adult Child Medi-Cal program eligibility you can, click here, to review the Disability Rights California publication entitled, Disabled Adult Child (DAC) Medi-Cal Program Benefits.

(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.4

Calculation – Couple under ABD MN

In this example, Alice and Alberto are a married couple. Their combined monthly Social Security income before Alberto’s Medicare deduction is $2,400 which after the $20 unearned income deduction and $297 Medicare premiums are deducted equals a net countable income of $2,083. They are not eligible for the ABD FPL program because their net countable income is above the ABD FPL couple income limit of $2,004. However, they may be eligible for ABD MN program with a Medi-Cal share of cost of $1,149.

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

Step 1

$2,400 (gross income) - $20 (unearned income deduction) - $148.50 (Alice’s Medicare Part B premium) - $148.50 (Alberto’s Medicare Part B premium) = $2,083 (couple’s countable income)

Step 2

$2,083 (couple’s countable income in step 1) - $934 (Maintenance Need Level or MNL for couple) = $1,149 (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.5

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

Long-Term Care (LTC) Medi-Cal is a Medi-Cal program for people who need nursing home level of care. This care can be provided at institutional long-term care facility or at home through home and community based services (HCBS).  If you need Long-Term Care (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 Long-Term Care (LTC) Medi-Cal, then you may use “spousal impoverishment protections” to allocate your income to your spouse in order to establish Medi-Cal eligibility without a share of cost.

Medi-Cal "spousal impoverishment protections" allows a Medi-Cal beneficiary who needs LTC Medi-Cal to give a limited amount of their income and resources to the spouse that does not need LTC Medi-Cal. This limit 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).  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. 

These limits on how much income and resources can be allocated to spouses goes up every year based on cost of living increases. In 2021, the community spouse’s Maximum Monthly Maintenance Needs Allowance (monthly income limit) is $3,260.00 and the community spouse’s Maximum Resource Allowance (resource limit) is $130,380.00.6

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 leftover in income/resources will be used to determine your eligibility for Medi-Cal.

TIP: If the Medi-Cal programs based on age or disability, then IHSS income cannot be deemed to the spouse for purposes of determining the disabled spouse’s Medi-Cal eligibility.7

Calculation – Couple using spousal impoverishment protections

In this example, 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.

A. 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: 2021 Maximum Monthly Maintenance Needs Allowance (maximum monthly income limit) is $3,260.00.  Alice’s income is a $700 pension.

$3,260.00 (maximum monthly income limit for Alice) - $700 (Alice’s pension) = $2,560 (amount of money Alberto can allocate to Alice).  Alberto can allocate a maximum of $2,560 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 $1,482 for a household of 1.

B. 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 Allowance (resource limit) is $130,380.00.

Alice and Alberto have $80,000 (in resources) in savings.  $80,000 (savings) is less than $130,380.00 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 a zero share of cost Medi-Cal under the ABD FPL program.  This is because he has no income and no resources.

(i) Access to Medi-Cal through   – Home and Community Based Services Waivers

If an individual is ineligible for LTC Medi-Cal services 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 through one of Medi-Cal’s home and community-based services waivers. Here is where you can find a list of California’s Medi-Cal waivers: https://www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx.

(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.

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  • 1. All County Welfare Directors Letter (ACWDL) 21-06.  The ABD FPL income limit is based on the greater of SSI payment rate (ACWDL 20-19) or 138% of the Federal Poverty Level (ACWDL 21-01).  For individuals who receive Social Security (Title II), their annual cost of living (COLA) shall be disregarded from January through March, i.e., until the new FPL limits go into effect.  At that time the ABD FPL ceilings will be increased and the individual’s current income will be used to determine eligibility. Additionally, the Medicare Part B premium disregard is now applied for individuals in this program who are eligible for Medicare Part B.  More information can be found in ACWDL 20-18. You can also find ABD FPL program incomes limits for households of more than 2 people on the Health Consumer Alliance website or visit https://healthconsumer.org/wp/wp-content/uploads/2021/01/HCA-FPL-Income….
  • 2. See DHCS ACWDL No. 02-38, Question 7.
  • 3. That includes SSI received for the 5th month of the waiting period before SSDI benefits start or the month before you first qualified for Disabled Adult Child benefits or when you first qualified for Social Security retirement benefits. This is because you receive Social Security Title II benefits for one month, in the following month. Thus, if you received SSI benefits in March and were also eligible for Title II benefits in March which you would not receive until April, you were eligible for and received both SSI and Social Security Title II benefits for the same month.
  • 4. You can also find maintenance need levels (MNL) for households of more than 2 people on the Health Consumer Alliance website or visit https://healthconsumer.org/wp/wp-content/uploads/2021/01/HCA-FPL-Income….
  • 5. Under the ABD MN program you deduct what you pay or are obligated to pay for necessary medical expenses to meet your Medi-Cal SOC.  Preferably starting with things not covered by Medi-Cal such as incontinence supplies, therapy, dental vision.  You may also want to visit DRC’s Healthcare Resources website for more information about how to use your SOC to get more services.
  • 6. All County Welfare Directors Letter (ACWDL) No: 20-27.
  • 7. 20 C.F.R. §416.1161(a)(16).

 

 

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