Your Benefits and YouA Medi-Cal primer, Part 2
By ROB LANGELIER
The April You and Your Benefits column covered the basics of the Medi-Cal program as well as broad Medi-Cal eligibility criteria and applying for coverage. This month we will examine Medi-Cal share of cost, the AIDS Drug Assistance Program (ADAP) and its relationship to share of cost.
Medi-Cal and share of cost can be complicated. The more you know, though, the better off you will be in protecting your own physical and financial health.
Share of Cost
Share of cost is a monthly deductible that is payable directly to doctors, hospitals, clinics, therapists, dentists and other health care providers. It is used to help reduce the total costs that Medi-Cal pays for health care and it expands Medi-Cal eligibility to allow more people with higher incomes to be eligible for Medi-Cal than would otherwise be possible.
Medi-Cal is a needs-based program. Disabled individuals with an income of less than $620 a month used to be meet the "need" requirements. This criteria excluded SSI (Supplemental Security Income) recipients because they were automatically eligible for zero share-of-cost Medi-Cal. It did, however, leave many people with low, fixed incomes without proper health care coverage.
To address this problem, share of cost was created. It is formulated using a simple calculation to deal with income above $620 or as Medi-Cal calls it, the $620 monthly maintenance need. Share of cost permits $620 a month in income and the remaining portion of the monthly income is put toward an eligible recipient's share of cost.
To put it another way, people who receive Medi-Cal because they are disabled are allowed a monthly maintenance need of $600 plus an additional $20 for being disabled. This combined $620 is subtracted from their monthly income and the remaining dollar amount equals their share of cost.
For example, if a person with an SSDI (Social Security Disability Insurance) income of $820 applies for Medi-Cal their share of cost calculation would be:
$820 SSDI Income
In the above example, an individual would have to pay $200 a month in share of cost before Medi-Cal would pay any portion of their medical expenses.
Confusing formula
How share of cost is applied and paid confuses many people.
Many Medi-Cal recipients think they are required to pay their full share of cost each month in order to keep their Medi-Cal coverage or they think that share of cost is a monthly insurance premium. Neither is true.
Share of cost is simply what Medi-Cal would like you to pay toward your own health care before Medi-Cal pays for any bills on your behalf. If you do not generate any medical costs in a month or if you don't generate bills in excess of your share of cost you are not required to pay your full share of cost. In essence your share of cost simply limits your out-of-pocket monthly health care expenses.
When is it necessary to pay your share of cost? Whenever your medical expenses for any month exceed your share of cost.
Borrowing from the example above, imagine that your share of cost is $200. Let's also imagine that you went to see your treating physician on March 1 and she billed you $500 because you required a costly in-office medical procedure. You would pay your physician directly $200 (your total share of cost), and Medi-Cal would pay your doctor the remaining $300.
This would mean that on March 1, your total share of cost would have been met with this office visit. Any bills generated for your health care after that visit and for the remaining portion of March, would be billed, in total, directly to Medi-Cal because your share of cost was paid in full.
Let's say that you went to see a chiropractor on March 3 and the bill was $85. The entire $85 bill would be sent directly to Medi-Cal because your share of cost would have already been paid for March because of your doctor's appointment on March 1.
Remember, Medi-Cal recipients pay share of cost directly to their health care providers and never to Medi-Cal or The Department of Public Social Services (DPSS), the Los Angeles County agency responsible for administering Medi-Cal locally.
ADAP benefits
Additional relief in managing your share-of-cost expenses can be found in AIDS Drug Assistance Program (ADAP), a federal- and state-funded program that provides access to low-cost or free HIV-related medications for eligible, HIV-infected people.
ADAP eligibility guidelines are fairly liberal. A single person with an income of less than $32,200 can receive HIV medications free of charge. People who earn between $32,201 and $50,000 are also eligible for low-cost assistance in paying for their HIV-related medications.
Most importantly, ADAP provides an invaluable service for Medi-Cal recipients who do not have additional private insurance. ADAP clears the share of cost for clients who are enrolled in ADAP, who are receiving Medi-Cal with a share of cost and who are currently using HIV prescription medications.
ADAP does this by paying for the lower cost of your share of cost, as opposed to paying for the full cost of your prescription medications. This saves money for both you and the ADAP program.
For most people, monthly share of costs are much lower than their HIV medications bill. ADAP realized that clearing share of cost was a much more cost effective assistance than paying for the total monthly prescription medication charges of their Medi-Cal eligible clients.
One caveat: ADAP does not clear the share of cost for clients on Medi-Cal who also have private health insurance. Private health insurance includes those ADAP clients who also have health coverage through a Medicare HMO. If you are enrolled in a private health plan, ADAP will pay for your HIV medication co-pays but they will not be able to clear your share of cost.
To apply for ADAP services in California, contact PMDC at (888) 575-2327 or (888) 311-7632. Both phone numbers are toll free.
Other strategies
Reducing your share of cost can also be done in other ways. To learn more about managing your share of cost or if you have any additional questions about Medi-Cal applications or eligibility, feel free to call (323) 993-1478.
Rob Langelier is a Medi-Cal specialist in AIDS Project Los Angeles' Benefits Program. He can be reached by calling (323) 993-1478 or by e-mail at rlangelier@APLA.org. |