Navigating Medi-Cal's Share of Cost to Access CalAIM Benefits in California
For individuals in California securing a managed Medi-Cal plan to participate in the CalAIM program requires strategically eliminating a "share of cost." This comprehensive guide outlines the best methods to achieve this, based on the latest available information for 2025.
CalAIM (California Advancing and Innovating Medi-Cal) is a transformative initiative designed to improve the quality of life and health outcomes for Medi-Cal beneficiaries.1 It mandates enrollment in a managed care plan for most participants to access enhanced care management and community support services. However, individuals with a monthly income exceeding certain limits may be assessed a share of cost (SOC), which is a predetermined amount they must pay for medical expenses each month before Medi-Cal coverage kicks in. For example, for members who have a monthly income of $2,500, an individual would typically face a significant SOC.
Understanding the Share of Cost Calculation
Your share of cost is determined by your "countable income." To calculate this, Medi-Cal first allows certain deductions from your gross income. For the Aged, Blind, and Disabled (ABD) Medi-Cal program, which is relevant in this scenario, your share of cost is the difference between your countable income and the Maintenance Need Level (MNL).2
Key Figures for 2025 (Projected):
Aged, Blind, and Disabled (ABD) Federal Poverty Level (FPL) Income Limit: For no-cost Medi-Cal, your countable monthly income must be at or below this limit, which is projected to be around $1,801 for an individual in 2025.3
Maintenance Need Level (MNL): This is the amount of income Medi-Cal allows you to keep for living expenses. A significant change is anticipated for 2025. The MNL for a single individual is expected to increase from the long-standing $600 per month to 138% of the Federal Poverty Level. Based on recent data, this would be approximately $1,677.
With a monthly income more than your countable income will likely exceed the no-cost Medi-Cal limit, resulting in a share of cost. The primary goal is to reduce your countable income to at or below the MNL.
Top Strategies to Eliminate Your Share of Cost
Here are the most effective, legal methods to reduce your countable income and eliminate your share of cost:
1. Deduct Health, Dental, and Vision Insurance Premiums:
This is the most direct and widely used strategy. The monthly premiums you pay for any health, dental, or vision insurance are deducted from your gross income when calculating your countable income.
How it Works: By purchasing a supplemental insurance plan, you can strategically lower your countable income. For example, if your countable income is $1,900 and the MNL is $1,677, you would have a share of cost. However, if you purchase a dental and vision plan with a combined monthly premium of $225 or more, your new countable income would be at or below the MNL, eliminating your share of cost.
What to Do: Shop for affordable dental and/or vision plans. The cost of these premiums will likely be significantly less than the share of cost you would otherwise have to pay. Once enrolled, provide proof of your premium payments to your county's Department of Public Social Services (DPSS).
2. The Working Disabled Program (WDP):
For individuals with a disability who are working, the Working Disabled Program offers a powerful way to obtain full-scope Medi-Cal with no share of cost. This program has much higher income limits and does not count disability-related income.
Eligibility: To qualify, you must meet the Social Security definition of disability (though you don't need to be receiving Social Security disability benefits) and be employed. There is no minimum number of hours required.
Income Limits: The countable income limit for the WDP is 250% of the FPL, which is significantly higher than the limit for regular ABD Medi-Cal.
How it Can Help: If you are able to work even a small amount, this program can be an excellent option to bypass the share of cost issue altogether.
3. Incurred Medical Expenses (Spend-Down):
If you have recurring medical expenses, these can be used to "spend down" your income to meet the MNL for a particular month.
How it Works: You submit paid medical bills (for services, prescriptions, etc.) to your county DPSS office. These expenses are deducted from your income for that month. Once your medical expenses equal your share of cost, Medi-Cal will cover the remaining approved medical costs for the rest of that month.
Considerations: This method is less predictable than deducting insurance premiums as it relies on having sufficient medical expenses each month. It does not eliminate the share of cost in advance but rather helps you meet it.
CalAIM and Your Managed Care Plan
Once you have successfully eliminated your share of cost and qualify for a managed Medi-Cal plan, you will be able to fully participate in the CalAIM program. This will give you access to a coordinated care team and a broader range of services designed to address your overall health and well-being, including:
Enhanced Care Management (ECM): A dedicated care manager to help you navigate the healthcare system, connect with services, and manage your health conditions.6
Community Supports: Services that address the social drivers of health, such as housing navigation, medically tailored meals, and caregiver respite.
Important Steps to Take:
Contact Your County DPSS Office: Speak with an eligibility worker to confirm the current MNL for a single individual and discuss your specific situation. They can provide you with the most accurate calculation of your potential share of cost.
Explore Your Options: Carefully consider the strategies outlined above to determine which is the most suitable for your circumstances.
Gather Documentation: Be prepared to provide proof of income, expenses, and any insurance premiums to your eligibility worker.
Stay Informed: Medi-Cal rules and income limits can change. Regularly check the California Department of Health Care Services (DHCS) website for the latest updates.
By proactively managing your countable income, you can eliminate your Medi-Cal share of cost and unlock the comprehensive benefits offered through a managed care plan under the CalAIM program.