Medi-Cal eligibility is based on several factors, a few of which include income, assets and immigration status. 

  • Family Income: Income limits depend largely upon which group each beneficiary falls into. For instance, the income limit for infants and children under 19 is 250% of the federal poverty level. But for parents, the income limit is 100% of the federal poverty level.
  • Family Assets: The upper limit to the value of all assets is typically around $2,000 for one person, and increases with the size of the family. The type of things that are counted into the overall asset total include savings, checking, stocks, bonds and certain life insurance policies and annuities. The home is usually not covered.
  • Immigration Status: In addition to California residency, full Medi-Cal coverage is available to those with Lawful Permanent Residency, green card holders, refugees and immigrants granted asylum.
As part of the 2008 Federal Deficit Reduction Act, people applying for or renewing their Medi-Cal coverage must present proof of citizenship (such as birth certificate) and identity (such as driver’s license).

Services & Benefits

The covered services include primary, acute, and long term care. There are no premiums or copayments for those beneficiaries with the lowest-income. Below are some of the main services that all Medicaid programs are required to provide under federal guidelines:
  • Inpatient and Outpatient Services
  • Physician visits
  • Laboratory tests and x-rays
  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for children under 21
  • Family planning and supplies
  • *Pregnancy-related services, including 60-days postpartum care

*Medi-Cal has allowed only a narrow range of diagnosis codes which can be billed in conjunction with certain procedures. Unless there was something specifically wrong with the patient’s pregnancy or medical condition, Medi-Cal will deny certain CPT codes based on the assertion that there is not enough justification to validate that particular procedure (e.g. fetal monitoring, ultrasound or urinalysis). EDS has made it clear that they will not pay for “unnecessary procedures” based solely on the fact that the patient is pregnant. In other words, pregnancy alone does not constitute a “medical necessity” according to Medi-Cal. Also, a majority of the procedures can only be billed once every six months unless there is medical justification. Again, pregnancy itself does not count.