California’s Criteria for Dual-Eligibles

April 23, 2012

Well before the PPACA was enacted, certain individuals over age 65 or collecting federal disability payments may be eligible to participate in both Medicare and Medicaid (termed “Medi-Cal” in California). Such an individual is termed a “dual eligible.” The advantages to dual-eligibility include greater financial assistance and access to services which may not be available under Medicare alone. A dual eligible must meet the requirements of both programs.

Medicare criteria are:

1. Age (65 or over),
2. Ten years of Medicare-eligible employment prior to age 65, and
3. U.S. citizenship or, if an immigrant, compliance with Medicare’s immigration criteria.

Medicaid/Medi-Cal is a social safety net health care program for qualifying low-income individuals. Eligibility criteria are Byzantine, especially in California, as Medi-Cal contains over 90 eligibility categories, each with its own rules and requirements.

The following highlights California dual-eligibility criteria.

The California Department of Health Care Services (“DHCS”) is the administering state agency for Medi-Cal. Further, California permits each county to operate with considerable autonomy, having authorization to determine eligibility, at least in circumstances when the NPL is less than 150%.** Additionally, each county can individually interpret the state’s guidelines for eligibility. Therefore, if a dual eligible beneficiary moves to a different county, they may not be eligible in their new location.

The rules applied most often to determine Medi-Cal eligibility for the elderly (defined as age 65 or older) are broken down into “personal characteristics” and financial limits.

To meet the category of personal characteristics, the applicant must supply verification of California residency, and be a U.S. citizen or meet proper immigrant status.

To meet the financial criteria, the applicant must meet one of the various low-income tests, which include:

1. Countable assets valued at less than $2,000 for an individual. Assets excluded from this category are one’s primary personal residence, an automobile, a life insurance/burial policy valued at less than $1,500, household goods and personal belongings, and a prepaid burial plan (unlimited if irrevocable or up to $1,500 if revocable) and burial plot. Life insurance policies and Individual Development Accounts (IDAs) are also exempt.

2. Income criteria, as determined in a number of ways:

At the date of this writing, one’s gross monthly income, if living alone, must be no greater than $1,138 as set forth in the Medi-Cal/Healthy Families Income Levels. The data in this chart is derived from the National Poverty Level (NPL).

In the federal Medicaid framework, beneficiaries are divided into three groups: 1) Mandatory Categorically Needy, also known as a Qualifying Medical Beneficiary (QMB); 2) Optional Categorically Needy; and 3) Medically Needy.

A QMB falls within the Mandatory Categorically Needy, and each state is required to provide Medicaid coverage for an eligible individual who is a QMB. Most often, the aged Medicare recipient will fall within the Mandatory Categorically Needy designation. If so, eligibility requires that he is entitled to Medicare Part A. Qualifying income is limited to 100% of NPL or less and resources may not exceed twice the limit for SSI eligibility. Expenses covered include the Medicare Part A deductible, the Medicare Part B premium and the Medicare Part B deductible.

The Optional Categorically Needy category is defined by the Qualifying Individual (QI) Program. Eligibility requirements include entitlement to Medicare Part A, an income of at least 120% but less than 135% of the NPL and resources not exceeding twice the limit for SSI eligibility, and not otherwise eligible for Medicaid benefits. Expenses covered include the Medicare Part B premium.

Eligibility for the Medically Needy category, defined as the Specified Low-Income Medicare Beneficiary (SLMB) Program, requires eligibility for Medicare Part A, an income above 100% but less than 120% of the Federal Poverty Level, and resources not exceeding twice the limit for SSI eligibility. Expenses covered include the Medicare Part B premium and the cost of additional health services and prescriptions if the applicant qualifies for full Medicaid services (SLMB Plus).

The QI Program differs from the SLMB Program as follows:

Each year, the state has only a certain amount of money for this program;
Once the money runs out, no one else will be enrolled;
Eligible beneficiaries receive assistance on a first-come, first-served basis; and
Beneficiaries must re-apply for the program every year.

Federal law only requires that states provide coverage to individuals who fall within the mandatory categories of eligibility. Consequently, states may choose whether or not to cover individuals who are classified as Optional Categorically Needy or Medically Needy (in which the income standard is called the “medically needy” income level). The Medically Needy qualify for a federal eligibility category, even though their income or resources exceed the categorically needy levels. States electing to include the medically needy must use a single resource eligibility standard and a single income eligibility standard.

California currently offers all optional programs. The income level and other resources determine which program the individual should apply for. The fact that other states do not offer all three optional Medicaid programs to the low-income aged complicates administering Medicaid both on a federal level – especially with regard to evaluating parity between the states and auditing each state’s’ use of federal funds.

Note: If one is no longer eligible for her current Medi-Cal program, a county must determine if she is eligible for other Medi-Cal programs before terminating coverage.

*Recently, there was a new twist in the application of health care reform. “The Obama administration said that it would not define a single uniform set of ‘essential health benefits’ that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories. The move would allow significant variations in benefits from state to state, much like the current differences in state Medicaid programs….”  The Times subsequently ran an Op/Ed discussing (and disapproving) the ramifications of this decision.

** Recent 2011 DHCS promulgations specify that if the applicant’s income surpasses the 150% NPL, a state contractor, Maximus, may determine eligibility. Please see

The above is a synopsis of the criteria needed to be eligible for both Medicare and Medi-Cal. Please note that this is an overview only, and that you should consult a social worker or agency representative to discuss your personal situation.

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