 | | | Medi-Cal: Common Pitfalls | | | | | | | | |
Basing Decisions on Misinformation |
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Most of us usually rely on the experience of others to understand how to deal with similar situations. The real problem with this is that benefits are person-centered. Benefit programs fit each individual differently, based on a variety of facts and conditions, such as:
- your work history;
- how much you earn;
- what you own;
- how disabling your condition is;
- how clearly you report the details of your condition to your medical provider;
- how well your medical provider understands or documents these details;
- what benefits an employer provides; and
- what benefits you have purchased individually.
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Lack of documentation |
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The more specifically you document your medical condition, the easier it will be to support a claim and to make a case for continuing benefits. Detailing in a daily journal even the most seemingly insignificant symptoms can be of great value. If you or the individual are too ill, or can't maintain the journal on a daily basis, a friend or relative can log the entries. This journal can also provide you with a way to inform providers about your medical condition.
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Denial of Your Disability |
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It is common for individuals to have periods of time when they deny to themselves, their families, and medical provider(s) that a disabling condition exists. For some, it is an approach to coping with a new condition. During this period of time, the individual’s communication with medical providers may not accurately or fully describe the severity of a condition or how seriously it affects day to day activities.
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Not Knowing Which Medi-Cal Program You Are Enrolled In |
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Acting on Bad Information |
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It can be difficult to find accurate and complete information about Medi-Cal programs. Keep in mind that if your circumstances change, it may be more cost effective to consider another eligibility category of Medi-Cal. Some social workers and advocates may have limited knowledge of Medi-Cal programs and private health coverage options. They also may be unaware of how income and employment changes may impact your Medi-Cal eligibility. It is important to verify that the information you receive is accurate and complete. |
Underreporting Your Earnings |
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If you underreport earnings, you may lose eligibility for a Medi-Cal program. Make sure to report all of your gross income. Gross income is the amount paid before taxes are deducted from your paycheck. If you are self-employed, you can report earnings based on your IRS tax return. Earned income, in some cases, may allow you to access a more cost effective eligibility category of Medi-Cal such as the 250% California Working Disabled Program. |
Not Keeping Complete Earnings Records |
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It is your responsibility to maintain accurate and detailed records. The earnings you report to Medi-Cal will be verified. Clearly document all communication with Medi-Cal. Make copies of letters and keep records of phone conversations, including the date and time phone calls take place and the name of the individual who was assisting you. These steps can help you avoid pitfalls during the application process and while maintaining eligibility for benefits. Many people keep a journal of Medi-Cal contacts in a spiral notebook.
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Confusion About Wages and Countable Income Rules |
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When determining eligibility in the program, Medi-Cal does not consider the entire amount of your earnings. See the program description of the particular programs to see how income is counted and what further deductions you may be able to make from your gross income.
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Not Knowing Which Medi-Cal Program You Are Enrolled In |
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Fear of Losing Medi-Cal |
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If you are receiving Medi-Cal through SSI, you may have concerns about earning wages that would put your total countable income at the break even point. When income exceeds the break event point you may be at risk of losing Medi-Cal coverage. However, if you meet all of Social Security’s 1619(b) provisions you can continue receiving Medi-Cal. Another option is to apply for a personal threshold amount through Social Security. |
Loss of health coverage due to late premium payments |
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Not meeting the health insurance requirements |
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Medi-Cal/HIPP cannot be used for the purchase of a new health insurance policy. You must have an existing health insurance policy (or have one available through your employer) when you apply. Your insurance can be individual, group, continuation coverage, such as COBRA, Cal-COBRA, or OBRA (for self-insured trusts), or a COBRA conversion policy. Your policy must cover your high-cost medical condition. |
Not meeting the share of cost requirement |
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You must either be in a Medi-Cal category that does not have a share of cost OR have a share of cost that does not exceed $200 per month to qualify for Medi-Cal/HIPP. Any monthly income in excess of $600 ($620 for individuals with disabilities) becomes your share of cost under Medi-Cal. If you have a share of cost that exceeds $200 per month, you still may be eligible for Medi-Cal/HIPP. To qualify you must either:
- Pay for the private insurance premium during the month you apply for the HIPP program; or
- Use unpaid medical bills to be applied towards a future share of cost. This can be done under Hunt v. Kizer case law that allows individuals to use unpaid medical bills towards a Medi-Cal share of cost during the initial application process.
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Not submitting information to Medi-Cal/HIPP in a timely manner |
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Medi-Cal/HIPP pays premiums on the 20th of each month. Premiums are paid one month in advance. Applications must be submitted early in the month in order to process and disburse premium payments on time. Medi-Cal/HIPP does not pay prior premiums. In addition, any changes that are made to the premium amount must be submitted to Medi-Cal/HIPP early in the month in order to process and disburse the premium payment on time to avoid any interruption in coverage.
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