During the COVID-19 pandemic, federal rules prevented Medi-Cal from disenrolling people because of changes in income. These rules ended with the Consolidated Appropriations Act of 2023. Many dually eligible beneficiaries enrolled in managed care plans around Medicare and Medicaid. These plans have integrated member materials. Learn about these Medicare and Medi-Cal plan options at the CalAIM Managed Care Enrollment Outreach Webpage.
New Eligibility Criteria
Medi-Cal is a program that provides healthcare access for individuals who meet certain income requirements. It is available to seniors, children, pregnant women, disabled adults, individuals with certain medical conditions, such as tuberculosis and HIV, and those residing in nursing or intermediate care homes. It is also available to individuals in certain family situations, such as parents of eligible children and temporary refugees living in the U.S. Typically, an individual must meet some income requirements and provide proof of their income to qualify for Riverside County Medi-Cal services, similar to the process required to apply for Social Security benefits. In addition, many people who receive Medi-Cal are subject to asset limits. The state sets these limits, which typically vary by county.
Medi-Cal’s assets include any liquid investments not used to pay for housing, food or clothing. Additionally, a married couple’s assets are counted together, even if only one spouse applies for Medicaid coverage. The assets counted by Medi-Cal will be raised to 138% of the federal poverty level, or $1,564 a month for a single person and $2,106 a month for a couple. For individuals with a share of the cost, their monthly income will be adjusted so that their net income is no higher than this amount, which acts as a medical deductible.
Eligibility Redetermination
Thanks to the federal COVID public health emergency declaration, Medicaid programs like Medi-Cal have been able to waive annual eligibility renewals or dis-enrollments for three years. The pause contributed to a huge surge in enrollment, and now that it’s over, the yearly renewal process is resuming—and dis-enrollments are expected to start rising again. It is a big concern, especially for those living in poverty. Churning can cause people to lose their coverage and create barriers for those who need help accessing the marketplace and getting subsidized health insurance in Covered California. That’s why the state needs to ensure that counties are ready and that a transparent plan is in place to monitor churn. The state also has a new method to avoid disruptions in the marketplace. It will reopen the market for Medi-Cal managed care, but it won’t require the competitive bidding process that was originally planned. Instead, the department has negotiated contracts with five commercial health plans.
Eligibility Changes for Children
In April 2023, the state will resume its normal renewal process, which will take place over 14 months and redetermine the eligibility of around 15 million Medi-Cal enrollees. Many of these individuals will be automatically re-enrolled, but some may have to fill out forms or attend an interview to prove they still qualify. They could lose their free or low-cost health insurance if they do not submit the required information or are found to allow no longer. Disability rights advocates worry that a variety of administrative and procedural barriers could result in people being disenrolled, with low-income people and communities of color at greater risk due to structural inequities. The redetermination process will affect most dually eligible individuals, including those with Medicare and Medi-Cal managed care coverage. However, those individuals will receive separate notices with information about their options, including making a managed care plan selection or being added to a state-selected Managed Care Organization (MCO) program. In addition, those dually eligible individuals with Medicare Advantage plans or Original Medicare will continue to see their Medicare doctors and hospitals as usual. While it is still being determined how many Californians will be disenrolled, research suggests that 65% of people who drop off Medi-Cal will go without coverage for some time. At the same time, the vast majority remain eligible to get covered through the state’s health marketplace or their employer.
Eligibility Changes for Adults
The new rules for 2023 allow low-income adults to earn more without losing their Medi-Cal benefits. It will help consumers avoid the churn that has resulted in people leaving the program or facing gaps in their coverage during recent dis-enrollment events. For dual-eligible individuals enrolled in managed care, it will also be important to ensure they receive accurate information about their options to keep their health coverage. State and county officials have known for months that regular eligibility reviews would restart in April, but many people who have been enrolled in Medi-Cal for decades may have yet to be aware of this change. Some advocates worry that this churn could cause people to lose their coverage, with low-income and people of color at higher risk due to structural barriers in the system. Advocacy groups have created a resource to share with their members to ensure they know what steps they need to take.
