If your monthly income is above the Medi-Cal limit, you may still qualify — but with a Share of Cost. Here's what that means for accessing PCHS, Respite, and other CalAIM services.
A plain-language explanation of how Medi-Cal works when income is above the free-coverage limit.
Medi-Cal Share of Cost is the monthly amount a Medi-Cal beneficiary must pay (or accrue in medical bills) before Medi-Cal will start paying for their care that month. It works much like a monthly deductible.
SOC applies to people whose countable income is above the Medi-Cal Aged, Blind, & Disabled (ABD) income limit but who still qualify for Medi-Cal under the "Medically Needy" program. Without SOC, they would not have Medi-Cal at all.
Bottom line: A person with a Share of Cost still has Medi-Cal — and is therefore still eligible for CalAIM PCHS, Respite, and IHSS — but they must "meet" their SOC each month for Medi-Cal (and CalAIM services) to be active.
SOC is set by the county each year using a simple formula based on income and the state's Maintenance Need Level.
Note: The Maintenance Need Level for an individual is $600/month and for a couple is $934/month — figures California has kept unchanged for many years. The state is in the process of reforming SOC; check current numbers with your county or your Managed Care Plan.
CalAIM Community Supports (PCHS and Respite) are available to any full-scope Medi-Cal beneficiary enrolled in a Managed Care Plan — including beneficiaries with a Share of Cost — as long as the SOC is met for that month.
Each month, the beneficiary must submit medical bills, prescription receipts, or other allowable expenses equal to their SOC amount. Once SOC is met, Medi-Cal activates for the rest of that month and CalAIM services can be authorized and paid.
The cost of authorized PCHS or Respite hours provided in a month can be applied against the beneficiary's Share of Cost. For many clients, the value of their authorized in-home care meets or exceeds the SOC by itself.
Report income changes to your county Medi-Cal office promptly. A drop in income may lower or eliminate your SOC — sometimes converting a Share-of-Cost case to no-cost Medi-Cal.
Practical ways beneficiaries and families can satisfy SOC so CalAIM services activate.
Not necessarily. Many beneficiaries meet their SOC through bills they would already be incurring — prescriptions, equipment, doctor co-pays — or through the value of their CalAIM-authorized care. You only pay out of pocket if your bills fall short of your SOC for that month.
Yes. As long as you are enrolled in Medi-Cal Managed Care, your plan offers PCHS/Respite in your county, and you meet your SOC each month, CalAIM Community Supports are available to you.
A co-pay is a small fee per service. SOC is a monthly amount you must accrue in bills before Medi-Cal turns on at all that month. Once SOC is met, Medi-Cal pays for covered services without co-pays for most beneficiaries.
IHSS itself doesn't impose a separate share of cost — IHSS uses the same Medi-Cal eligibility. If you have a Medi-Cal SOC, your IHSS hours can also count toward meeting it, the same way CalAIM PCHS hours do.
California has been gradually reforming SOC rules and raising the Aged, Blind, & Disabled income limit. For the most current SOC numbers and policy changes, check with the California Department of Health Care Services (DHCS) or your county social services office.
Your county Medi-Cal worker can explain your SOC notice. Your Managed Care Plan's care manager and the Divine Agape intake team can also help you understand how SOC interacts with your PCHS or Respite authorization.