What disqualifies you from Medi-Cal largely depends on not meeting the program's eligibility requirements, primarily related to income limits and other specific criteria.
Medi-Cal, California's Medicaid program, provides essential health coverage to low-income individuals and families. While eligibility rules can vary based on the specific Medi-Cal program you are applying for (e.g., families with children, pregnant individuals, adults, seniors, or people with disabilities), the core reasons for disqualification generally revolve around financial thresholds and other non-financial criteria.
Primary Disqualifying Factors
The most common reasons an applicant might be disqualified from Medi-Cal relate to their financial situation:
1. Exceeding Income Limits
Medi-Cal is a "means-tested" program, meaning eligibility is determined by your household income compared to the Federal Poverty Level (FPL). If your Modified Adjusted Gross Income (MAGI) is above the specified limit for your household size and eligibility group, you will typically be disqualified from full-scope Medi-Cal.
- For Adults (ages 19-64): Generally, adults must have an income at or below 138% of the FPL.
- For Children and Pregnant Individuals: Higher income thresholds usually apply, often up to 266% of the FPL for children and 213% for pregnant individuals.
- For Seniors and Persons with Disabilities (SPD): While income limits apply, specific programs for these groups might have different rules, and certain medical expenses can be used to "spend down" income if it's slightly above the limit.
Example: If a single adult earns more than 138% of the FPL, they would likely be disqualified from the Medi-Cal expansion program for adults.
2. Exceeding Property/Asset Limits (Historical Context)
Historically, or under previous program rules, exceeding property or asset limits was a key factor in Medi-Cal eligibility, particularly for certain long-term care programs or for seniors and persons with disabilities. In such cases, if an applicant's property or assets were over the Medi-Cal property limit, they would not be eligible unless they lowered their property or assets according to program rules.
Current Status: As of January 1, 2024, California has eliminated asset limits for all Medi-Cal programs, including those for seniors, persons with disabilities, and long-term care. This means that for most applicants, the value of their property, savings, or other assets no longer impacts their Medi-Cal eligibility. This significant change aims to make Medi-Cal more accessible and simplify the application process.
Other Non-Financial Disqualifying Factors
Beyond income, other factors can lead to disqualification:
- Residency: Not being a resident of California. Medi-Cal is a state-specific program.
- Citizenship/Immigration Status: Not being a U.S. citizen, legal permanent resident, or meeting specific qualified non-citizen criteria. While emergency Medi-Cal may be available regardless of immigration status, full-scope Medi-Cal generally requires eligible status.
- Failure to Provide Documentation: Not submitting required documents to verify income, residency, household size, or other eligibility criteria within the specified timeframe.
- Having Other Comprehensive Health Coverage: In some cases, if you have other comprehensive health insurance that meets your needs, you might not qualify for certain Medi-Cal programs, or Medi-Cal might act as a secondary payer.
- Failure to Meet Specific Program Criteria: Some Medi-Cal programs have specific criteria beyond income, such as age, disability status, or family composition. For instance, an adult without dependent children might not qualify for a program specifically designed for families.
Solutions and Practical Insights
If you are disqualified due to income or other factors, there might be alternative options or strategies:
- Covered California: If your income is too high for Medi-Cal, you may qualify for subsidized health insurance plans through Covered California, the state's health insurance marketplace. These subsidies can significantly lower your monthly premiums.
- Spend-Down Programs (Share of Cost): For some Medi-Cal programs, especially for seniors and persons with disabilities, if your income is slightly above the limit, you might be eligible for a "share of cost" Medi-Cal. This means you must incur medical expenses up to a certain amount each month before Medi-Cal begins to pay.
- Review Eligibility Annually: Eligibility requirements can change, and your household income or circumstances might also change. It's crucial to review your eligibility annually and report any changes.
- Seek Assistance: Applying for Medi-Cal can be complex. You can get free help from certified enrollers, county social services agencies, or community organizations to understand your options and complete the application accurately.
