Medi-Cal eligibility categories have complicated rules for how much money you can earn. So, when your income changes, it may affect your eligibility for Medi-Cal coverage. There are, however, a number of programs designed to help you keep your coverage when your income goes up.
Working Disabled Program
If you’re receiving free Medi-Cal and your income goes up because you are working, you may be eligible to switch to the WDP program. Medi-Cal workers are required to automatically check to see if you are eligible for this program when your income disqualifies you from your eligibility category. If they don’t, you should ask them to. You’ll have to begin paying for your Medi-Cal coverage, but the amount is small compared to the income you’re earning. See above for a description of this program.
SSI’s 1619(b) Provisions
If you’re on SSI-Linked Medi-Cal, and then your SSI benefit goes to zero because you go back to work, a section of the SSI regulations called the 1619(b) provisions allow you to keep your Medi-Cal coverage. In order to continue your Medi-Cal coverage under this program, you must:
- Have been eligible for an SSI cash payment for at least 1 month
- Still meet SSI requirements, like disability, blindness, or age, that don’t have to do with income
- Need Medi-Cal coverage to continue working, and
- Have less than $58,638 in gross earnings ($60,663, if blind) or have high medical expenses that will be evaluated on a case by case basis. Note that this program does not use the countable income calculation.
The $58,638 income limit is called a threshold amount. This is what Social Security calculates as the value of your SSI and Medi-Cal benefits. They determine this based on the SSI benefit in California, along with averages of medical costs in the state. So, if you’re earning enough money to replace the benefits and cover your medical costs without help from the government, then you’re usually not eligible for the program.
If your expenses are higher than the state average, Social Security may increase the threshold on a case-by-case basis. If you have IRWEs, BWEs, are contributing to a PASS, have a publicly funded personal assistant, or have medical expenses higher than the state average, you may be eligible for an individual threshold amount.
Pickle Amendment
When calculating your countable income, SSI considers any Social Security Disability Insurance (SSDI) or Childhood Disability Benefits benefits as unearned income. SSDI and CDB benefits increase every year to cover cost of living increases. This increase may be enough to make you ineligible for SSI, and the Medi-Cal linked to it. The Pickle Amendment protects Medi-Cal coverage for people in this situation. In other words, if you lose your SSI benefit because of a cost of living increase in your SSDI or CDB benefit, you can keep your Medi-Cal.
For more information, see Health Consumer Alliance’s excellent pamphlet on the Pickle Amendment.
If your income is too high for Medi-Cal, get help buying private insurance
If your income goes up so much that none of these rules help you keep your Medi-Cal and you cannot get coverage from an employer, you may qualify to get government help paying for a private health coverage plan on Covered California. If your family’s income is at or below of the Federal Poverty Guidelines (FPG), $36,450 for an individual ($75,000 for a family of four), the federal government will also help you get a plan that has lower copayments and other expenses.
Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG for federal subsidies and 600% of FPG for state subsidies.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.
Health Coverage Income Limits for Your Family
| Your family size: | |
Income limits for your family: | |
| Income-based Medi-Cal, adults (138% FPG) | |
| Income-based Medi-Cal, children (266% FPG) | |
| Subsidized private plans, reduced fees (250% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes:
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See DB101's Buying Health Coverage on Covered California article for more information.
