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Rules of Medi-Cal

Medi-Cal is California's Medicaid program, providing coverage to 6.8 million Californians. Medi-Cal offers health care coverage to low-income California residents who meet specific eligibility requirements. Applicants must be below predetermined income thresholds, and income received through programs such as Social Security can be factored into Medi-Cal's determination of an applicant's eligibility. Medi-Cal recipients can seek treatment through any participating health care provider for any health services defined as "medically necessary" by Medi-Cal.

  1. Factors in Determining Eligibility

    • Medi-Cal takes other factors besides income into account when determining an applicant's eligibility. If you're enrolled in California's SSI/SSP, Refugee Assistance, Adoption Assistance, In-Home Supportive Services or CalWorks programs, you're eligible for Medi-Cal enrollment. Applicants who are pregnant or have a disability receive preferential consideration for enrollment, as do applicants under 21 and over 65 years of age.

    Medical Necessity

    • Medi-Cal provides coverage for treatment that's "medically necessary," which is defined by California state law as medical attention required to preserve life, prevent disability, treat a serious illness or to relieve severe pain. Health care that's geared toward therapeutic rehabilitation that's required for a patient to resume normal physical activity is also covered by the state's definition. California doesn't regard experimental treatments as medical necessities and doesn't cover these procedures under Medi-Cal.

    Immigration Status

    • Immigrants with "satisfactory immigration status" (SIS) are eligible for Medi-Cal enrollment. Acceptable documents for establishing SIS include an I-551 Alien Registration Receipt Card, an I-151 Alien Receipt Card, an AR-3 or AR-3a Resident Card, an I-137 Re-Entry permit, or an I-94 Arrival/Departure Record stamped with "Refugee," "Political Asylum," Conditional Entry," or "Refugee." Immigrants who don't meet those criteria may only receive emergency care, pregnancy-related health care or long-term care that Medi-Cal administration deems appropriate.

    Assisted Living Coverage

    • A patient must be admitted to an assisted living facility under a doctor's orders for their care to be eligible for Medi-Cal assistance. These patients are allotted a personal allowance from their income by Medi-Cal, with the remainder to be used as payment for treatment. Homeowners receiving assisted living coverage may keep their homes if they state their intent to return home on their application for long-term Medi-Cal care.

    Limitations on Care

    • Medi-Cal limits the number of times patients can receive certain types of care each month. Treatment from psychologists, occupational therapists and physical therapists can only be received twice a month unless authorized by Medi-Cal. If authorization is given, the patient won't be covered for any other form of limited service that month. Children under 21 are exempt from this provision as long as their treatment meets the standard of medical necessity.

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