HIV Community Spotlight
Your Benefits and You
A Medi-Cal primer, Part 1
Medi-Cal is arguably the most important health insurance program for people living with HIV and AIDS in California. Yet hardly anyone in the HIV community understands the basics of this program. Why is that? Well, because Medi-Cal is really complicated!
As complex as Medi-Cal is -- and yes it is complex -- there are some basics that everyone infected with HIV, particularly people who are already Medi-Cal recipients, should know.
The most commonly asked questions about Medi-Cal are "What is Medi-Cal?", "Who is eligible for it?" and "What will Medi-Cal do for me?"
Just the facts!
Medi-Cal, also called Medicaid, is a publicly funded national health insurance program. It was established to guarantee access to quality health care for the blind, disabled, aged and other populations of people with limited resources or high cost medical needs.
Medicaid is the largest single payer of direct medical services for people living with AIDS in the United States. It serves more than 50 percent of all people with AIDS and up to 90 percent of all children with AIDS. It pays for a wide range of services including, but not limited to, prescription medications, surgeries, hospitalizations, durable medical equipment, pregnancy related services, mental health services, dental care, blood tests, X-rays, doctor visits and skilled nursing care.
Simply being HIV positive does not guarantee that a person will qualify for Medi-Cal.
Most people with HIV apply for Medi-Cal because they are disabled. Who does Medi-Cal consider disabled? If you are claiming that you are disabled due to HIV infection you must prove that you are unable to work because of your HIV-related illnesses or if you are working you must prove that you are unable to earn more than $700 a month or work 40 hours a week because your health prevents you from doing so.
Disability under Medi-Cal requires you to prove that your HIV-related symptoms or illnesses are expected to last for 12 months or more and are expected to continue to prevent you from being able to work full or part time.
Proof of medical disability is required. Disability is established by a full review of an applicant's medical records generally for the period of a year and a half before the date that the applicant claims is his or her disability on-set date. This review process can take up to six months to establish a final determination and may involve appeals if the applicant is denied.
One benefit of Medi-Cal, however, is that it accepts Social Security's decisions with regard to medical disability. That means that if you are currently considered disabled by the Social Security Administration you will not have to be evaluated again for medical disability with Medi-Cal.
Being medically disabled is not the only Medi-Cal eligibility criteria. Applicants must also prove that they have limited financial resources.
What does "limited financial resources" mean? If you apply as a single person, you must prove that your combined total assets are worth no more than $2,000 in order to qualify. One house, as long as you live in it, and one car are exempt as well as the first $1,500 of value of any burial trusts or burial insurance policies that you own.
Medi-Cal considers any money on hand, the value of any checking accounts, savings accounts, as well as 401(k) plans, KEOGHs, annuities, real property, cash value already available in life insurance policies, stocks, bonds, certificates of deposit, money market or mutual funds, mineral rights or mining claims that you may own to be assets. In essence Medi-Cal considers anything of value to be an asset.
Immigration and Medi-Cal
Legal residency or U.S. citizenship must also be proven in order to receive full-scope Medi-Cal.
If you are an undocumented person, you can apply for Medi-Cal using the same disability and financial needs criteria previously discussed.
If you are approved, however, your coverage will be limited to Restricted Medi-Cal. Restricted Medi-Cal provides coverage for emergency services and limited hospitalizations that are necessary to prevent death only. Restricted Medi-Cal will not pay for doctor visits or on-going health maintenance related costs but it does pay for pregnancy-related services.
How to Apply
So you think you qualify as a disabled person, and you have limited financial resources. What then?
AIDS Project Los Angeles provides a Medi-Cal Workshop every Tuesday night from 6:30 to 9:00 p.m. This workshop is open to anyone who is HIV positive.
Participants can apply for Medi-Cal in an HIV-supportive and friendly environment. APLA provides the complete Medi-Cal application as well as assistance in filling out the paperwork and guidance about the application process. We also submit completed applications to the Department of Public Social Services on behalf of workshop participants.
If you are unable to attend the workshop you may also apply at the Los Angeles County Department of Public Social Services. Locations that accept Medi-Cal applications can be found by calling the Los Angeles Central Help Line at (877) 481-1044.
If you live outside of L.A. County, applications for Medi-Cal are generally received and processed by your County's Social Services Agency. Most publicly funded hospitals and clinics also provide support and guidance with Medi-Cal applications.
An Imperfect Program
On paper, Medi-Cal is a tremendous program but it does have its failings.
Among the top complaints are that it is an enormous bureaucracy, that applying for coverage is a daunting process and that it can be difficult to find medical providers who accept Medi-Cal. Because it is such a vital program for the HIV community and because it does provide such enormous medical costs relief it is important for everyone who is HIV positive to understand the basics of Medi-Cal in order to be able to negotiate the system when needed.
In the next installment of this article, share of cost, ADAP and out-of-pocket Medi-Cal expenses will be discussed.
This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).
This article was provided by AIDS Project Los Angeles. It is a part of the publication Positive Living.