Understanding Medi-Cal Eligibility Requirements

Medi-Cal is California's Medicaid health care program that provides free or low-cost health coverage to eligible California residents. This comprehensive guide will help you understand the eligibility requirements for Medi-Cal and determine if you or your family members might qualify for coverage.

Overview of Medi-Cal

Medi-Cal is a critical healthcare safety net that serves over 14 million Californians—more than one-third of the state's population. The program provides a wide range of health services including:

Doctor visits and hospital care
Emergency services
Preventive care like checkups and immunizations
Prescription medications
Mental health services
Substance use disorder treatment
Dental care (Denti-Cal)
Vision care
Long-term care services (for eligible individuals)
Maternity and newborn care

Types of Medi-Cal Programs

Medi-Cal offers different programs to meet various healthcare needs:

Full-Scope Medi-Cal

Provides comprehensive coverage for all medically necessary services. Most eligible individuals receive full-scope coverage.

Restricted-Scope Medi-Cal

Limited to emergency services, pregnancy-related care, and long-term care. Generally available to individuals who don't qualify for full-scope coverage due to immigration status.

Medi-Cal with Share of Cost

For individuals with income above the standard Medi-Cal limits. Works like a deductible—you pay a predetermined amount for healthcare each month before Medi-Cal covers the rest.

Specialty Medi-Cal Programs

Medi-Cal Access Program (MCAP): For pregnant women with income too high for standard Medi-Cal
Breast and Cervical Cancer Treatment Program: For individuals diagnosed with breast or cervical cancer who meet specific criteria
Medically Needy Program: For individuals with high medical expenses relative to their income
250% Working Disabled Program: For working individuals with disabilities who have income up to 250% of the Federal Poverty Level

Basic Eligibility Requirements

To qualify for Medi-Cal, you must meet several basic requirements:

California Residency

You must be a resident of California to receive Medi-Cal. This means you currently live in California and intend to remain in the state. There is no minimum residency period requirement—you can apply as soon as you establish residency.

Proof of residency may include:

California driver's license or ID card
Utility bills in your name
Rental or mortgage documents
Employment documents
School enrollment records
Statement from someone who can verify you live in California

Citizenship or Immigration Status

Eligibility varies based on citizenship and immigration status:

U.S. Citizens and Nationals: Eligible for full-scope Medi-Cal if they meet other requirements
Lawful Permanent Residents (Green Card holders): Generally eligible for full-scope Medi-Cal
Refugees, Asylees, and Trafficking Victims: Eligible for full-scope Medi-Cal
Other Qualified Immigrants: May be subject to a 5-year waiting period, with some exceptions
Undocumented Immigrants:
- Children under 19: Eligible for full-scope Medi-Cal regardless of immigration status
- Young adults ages 19-25: Eligible for full-scope Medi-Cal regardless of immigration status
- Adults 26-49: Starting January 1, 2024, eligible for full-scope Medi-Cal regardless of immigration status
- Adults 50 and older: Eligible for full-scope Medi-Cal regardless of immigration status
- All undocumented immigrants: Eligible for restricted-scope emergency Medi-Cal

Note: Immigration information is only used to determine Medi-Cal eligibility and is not shared with immigration authorities for enforcement purposes.

Income Requirements

Medi-Cal uses Modified Adjusted Gross Income (MAGI) methodology to determine financial eligibility for most applicants. Income limits vary based on household size and the specific Medi-Cal program.

MAGI Medi-Cal Income Limits (138% Federal Poverty Level)

Household Size	Annual Income Limit (138% FPL)	Monthly Income Limit
1	$20,121	$1,677
2	$27,214	$2,268
3	$34,307	$2,859
4	$41,400	$3,450
5	$48,493	$4,041
6	$55,586	$4,632
Each additional person	+$7,093	+$591

Note: Income limits are updated annually based on Federal Poverty Level adjustments. These figures are current as of 2024.

Higher Income Limits for Children and Pregnant Women

Children ages 0-18: Up to 266% FPL
Pregnant women: Up to 213% FPL (covering prenatal care, labor and delivery, and postpartum care)

What Counts as Income?

MAGI income includes:

Wages, salaries, and tips
Self-employment income
Unemployment compensation
Social Security benefits (taxable portion)
Retirement and pension income
Rental income
Alimony (for agreements executed before 2019)

Some income is not counted, including:

Supplemental Security Income (SSI)
Child support received
Veterans' disability payments
Workers' compensation
Gifts and inheritances

Asset Requirements

For MAGI Medi-Cal (which covers most children, parents, pregnant women, and childless adults), there is no asset or resource test. Your eligibility is based solely on income.

However, for Non-MAGI Medi-Cal programs (primarily for seniors and people with disabilities), asset limits apply:

Individual: $2,000 in countable assets
Married couple (both applying): $3,000 in countable assets
Married couple (one applying): Special rules apply to protect the non-applicant spouse from impoverishment

What Assets Are Counted?

Countable assets include:

Cash
Bank accounts (checking, savings)
Stocks, bonds, mutual funds
Additional real property beyond your primary residence
Multiple vehicles (the primary vehicle is usually exempt)

What Assets Are Not Counted?

Exempt assets include:

Your primary residence
One vehicle
Personal and household items
Life insurance with face value under $1,500
Burial plots and burial funds up to $1,500
Retirement accounts (in some circumstances)

Household Composition

Your Medi-Cal household typically includes:

Yourself
Your spouse (if married)
Your tax dependents

Special rules may apply for children of divorced parents, pregnant women, and other situations. The household size directly affects your income eligibility thresholds.

Special Eligibility Categories

Beyond the standard eligibility pathways, Medi-Cal offers coverage for specific groups with special circumstances:

Children and Young Adults

Eligible for full-scope Medi-Cal with higher income limits (up to 266% FPL)
No immigration status requirements for children under 19
Young adults 19-25 are eligible regardless of immigration status
Former foster youth are eligible up to age 26 regardless of income

Pregnant Women

Higher income threshold (up to 213% FPL)
Coverage includes prenatal care, labor and delivery, and 60 days postpartum
Presumptive Eligibility for Pregnant Women (PE4PW) provides immediate temporary coverage while a full application is processed
Medi-Cal counts a pregnant woman as a household of at least two (more if expecting multiples)

Seniors (65+) and People with Disabilities

Several pathways to eligibility exist:

Aged & Disabled Federal Poverty Level Program: For those with income up to 138% FPL
Supplemental Security Income (SSI)-Linked Medi-Cal: Automatic Medi-Cal for SSI recipients
250% Working Disabled Program: For working individuals with disabilities with income up to 250% FPL
Medically Needy Program: For those with income above limits but high medical expenses (includes share-of-cost option)
Long-Term Care Medi-Cal: For those requiring nursing home care or equivalent home services

These programs often have asset limits and different eligibility rules than MAGI Medi-Cal.

Medicare Beneficiaries

If you have Medicare, you may qualify for one of these Medi-Cal programs:

Full Dual Coverage: Full Medi-Cal benefits plus Medicare premium and cost-sharing assistance
Medicare Savings Programs (MSPs):
- Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and B premiums, deductibles, and copayments
- Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Medicare Part B premiums only
- Qualifying Individual (QI): Helps pay Medicare Part B premiums for those with slightly higher incomes than SLMB

Former Foster Youth

If you were in foster care on your 18th birthday:

Eligible for full-scope Medi-Cal until age 26
No income or asset limits apply
Automatic eligibility regardless of where you lived when in foster care

Refugees and Trafficking Victims

Eligible for full-scope Medi-Cal if they meet income requirements
No 5-year waiting period applies
Special assistance may be available through Refugee Medical Assistance for the first 8 months

Presumptive Eligibility Programs

Presumptive Eligibility (PE) provides temporary Medi-Cal coverage while your full application is being processed. These programs include:

Hospital Presumptive Eligibility (HPE)

Immediate, temporary Medi-Cal coverage for individuals seeking care at participating hospitals
Coverage begins immediately and lasts up to 60 days
You must submit a full Medi-Cal application before the PE period ends to continue coverage

Presumptive Eligibility for Pregnant Women (PE4PW)

Immediate coverage for prenatal care
Available at many clinics and provider offices that serve pregnant women
Covers ambulatory prenatal care during the application process

Child Health and Disability Prevention (CHDP) Gateway

Provides temporary Medi-Cal coverage for children due for a CHDP health assessment
Automatically enrolls eligible children in temporary full-scope Medi-Cal

Accelerated Enrollment (AE)

Provides immediate temporary Medi-Cal for children pending a final eligibility determination
Allows children to access health services while their application is processed

Retroactive Coverage

Medi-Cal offers retroactive coverage for up to three months before your application month if you:

Were eligible for Medi-Cal during those months
Received medical services that would have been covered by Medi-Cal
Request retroactive coverage (either on your application or after approval)

This can help pay for medical bills you incurred before applying for Medi-Cal.

How to Determine Your Eligibility

Several tools can help you estimate your Medi-Cal eligibility before applying:

Covered California Shop and Compare Tool - Estimates your eligibility for Medi-Cal or subsidized coverage
MyBenefits CalWIN - Pre-screening tool for benefits eligibility
DHCS Do You Qualify for Medi-Cal? - Official information on eligibility requirements

Remember, these tools provide estimates only. The final determination is made after you submit a complete application.

Applying for Medi-Cal

If you think you might qualify, you can apply for Medi-Cal in several ways:

Online Application

Covered California - The state's health insurance marketplace
BenefitsCal - Apply for Medi-Cal and other benefits in one place

By Phone

Covered California: 1-800-300-1506
County Medi-Cal office (varies by county)

In Person

County social services office
Local community health centers
Some hospitals and clinics

By Mail

Download and print an application from DHCS
Mail the completed application to your county Medi-Cal office

Required Documentation

When applying for Medi-Cal, you may need to provide documents to verify your eligibility:

Identity and Citizenship/Immigration Status

Photo ID (driver's license, state ID, passport)
Birth certificate or passport (for citizens)
Immigration documents (for non-citizens)
Social Security Number or proof of application for one

California Residency

Utility bill, rental agreement, or mortgage statement
California ID or driver's license
Employment records
School enrollment records

Income Verification

Recent pay stubs
Tax returns
Self-employment records
Benefit award letters (Social Security, unemployment, etc.)

Assets (for Non-MAGI Programs)

Bank statements
Property deeds
Vehicle registration
Life insurance policies
Retirement account statements

Special Circumstances

Pregnancy verification
Disability documentation
Medicare card (for dual eligibility)
Foster care verification

Maintaining Your Eligibility

Once approved for Medi-Cal, you need to maintain your eligibility:

Annual Renewals

Medi-Cal eligibility is renewed annually
Many renewals are automatic using electronic verification
If additional information is needed, you'll receive a renewal packet
Complete and return any requested information by the deadline

Reporting Changes

You must report changes that may affect your eligibility within 10 days, including:

Income changes
Household composition changes (marriage, birth, adoption, etc.)
Address changes
Immigration status changes
New health insurance coverage

Report changes to your county Medi-Cal office or through your online account.

Appeals Process

If your Medi-Cal application is denied or your benefits are terminated:

Review the Notice of Action to understand the reason
Request a fair hearing within 90 days
Prepare documentation to support your case
Attend the hearing (in person, by phone, or by video)
If you disagree with the hearing decision, you may request a rehearing or judicial review

To request a fair hearing, call 1-800-952-5253 or submit a request in writing.

Additional Resources and Assistance

If you need help understanding Medi-Cal eligibility or applying for benefits:

Official Resources

Department of Health Care Services (DHCS) - Medi-Cal - Official program information
Covered California - Medi-Cal - Information on applying through the marketplace
County Medi-Cal Offices - Find your local office

Community Assistance

Health Consumer Alliance - Free assistance with Medi-Cal issues
Certified Enrollment Counselors - Available at community health centers
Legal Aid organizations - Help with complex eligibility issues and appeals

Language Assistance

Medi-Cal provides free language assistance services. When contacting Medi-Cal offices, you can request an interpreter in your preferred language.

Special Considerations

Transitional Medi-Cal

If you lose Medi-Cal eligibility due to increased income from employment or child/spousal support, you may qualify for up to 12 months of transitional Medi-Cal coverage.

Medi-Cal Estate Recovery

For beneficiaries age 55 or older, Medi-Cal may seek recovery from their estate after death for certain services received. Exceptions and limitations apply to this policy.

Medi-Cal and Other Health Coverage

You can have Medi-Cal and other health insurance simultaneously. Medi-Cal will coordinate with your other coverage and may help pay for costs not covered by your primary insurance.

Final Tips for Success

Apply even if you're unsure about your eligibility—many people qualify and don't realize it
Be thorough and accurate when completing your application
Respond promptly to all requests for information
Keep copies of all documents you submit
Note the name of representatives you speak with and the date of conversations
Report changes promptly to avoid benefit interruptions or overpayments
If denied, consider appealing or seek help from an advocate

Understanding Medi-Cal eligibility can be complex, but the benefits of having healthcare coverage are substantial. If you need healthcare and are concerned about costs, exploring your Medi-Cal options is well worth the effort.