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Understanding Share of Cost

What is Share of Cost?

Some consumers have income that is too high to qualify for IHSS or Medi-Cal. If they meet other eligibility requirements, they may still be eligible for both programs if they agree to a monthly Medi-Cal share of cost (SOC). The SOC is the amount that the individual will have to pay for services out of their own pocket, similar to a monthly deductible. This money can be paid to the IHSS provider, the consumer’s doctor, at the pharmacy, or can be applied to payments for any other Medi-Cal approved expenses.

How is SOC calculated? 

A consumer’s Medi-Cal SOC is determined by the following calculation:

Income – maintenance need level** – applicable deductions = SOC

** The current maintenance need level is $600 per month for a single adult. The level increases with each additional adult and child living in the household (i.e., $750 for one adult and one child, $934 for a family of three, etc.).

Example 1

Jane is an IHSS consumer who lives alone and has an income of $1,200 per month.

Jane’s Medi-Cal SOC is

$1,200 – $600 – $20 (a standard deduction) = $580 per month

Jane is responsible for paying $580 per month for IHSS and other Medi-Cal approved services.

Example 2

Mike is an IHSS consumer who lives with his son and has an income of $1,250 per month.

Mike’s Medi-Cal SOC is

$1,250– $750 – $20 (a standard deduction) = $480 per month

Mike is responsible for paying $480 per month for IHSS and other Medi-Cal approved services.

I have an SOC. Do I have to pay my IHSS provider?

The SOC is usually paid to whichever Medi-Cal approved services are used first during the month. Depending on the amount of your SOC and when you use specific services, the SOC could be paid during a visit to your doctor, during a trip to the pharmacy, or while receiving any other Medi-Cal approved service. After your IHSS provider has submitted his/her timesheet, the county will send you a notice letting you know how much of your SOC has been met for the month, and how much you will need to pay your IHSS provider as part of your SOC. Once your SOC has been met for the month, your provider will receive a paycheck for the remaining amount owed to him/her.

What if my SOC is too high?

If you have an SOC, you must pay that amount before Medi-Cal will pay for IHSS or any other Medi-Cal approved service or expense. However, there are several programs that can assist consumers with lowering or eliminating their SOC such as:

  • The 250% Working Disabled Program – allows an individual to earn an income and purchase full-scope Medi-Cal by paying a monthly premium
  • The Aged and Disabled Federal Poverty Level Program – provides free, full scope Medi-Cal services for seniors and individuals with disabilities who meet certain income and asset requirements (income must be below $1,138 per month for an individual and below $1,535 for a couple). Some consumers may be able to purchase a medical, vision or dental plan separate from Medi-Cal to spend down their income and qualify for this plan.
  • The Medi-Cal 1619b waiver – allows working SSI recipients to maintain eligibility for Medi-Cal even if their SSI payments have been reduced to $0
  • The Medi-Cal Pickle Program – provides free Medi–Cal to individuals who became ineligible for SSI due to COLAs for Social Security

For more information on how to qualify for these programs, contact your Medi-Cal eligibility worker. You can also contact the Legal Aid Foundation at 213-640-3926 for advice on SOC issues including how to spend down your income, and how your Medicare Part B premiums may effect your SOC. In addition, if you believe that your SOC has been calculated incorrectly, you can file an appeal by calling 800-952-5253.

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