What is Share of Cost (SOC)?

Share of Cost (SOC) is a financial obligation that individuals must meet before they become eligible to receive benefits under certain government assistance programs, particularly Medi-Cal in California. It is somewhat analogous to an insurance deductible in private health insurance plans. The purpose of SOC is to ensure that individuals with higher incomes but still facing significant medical expenses receive necessary assistance while also sharing in the costs of their care.

How Does Share of Cost Work?

1. Calculation: The Share of Cost amount is calculated based on the individual’s income, allowable medical expenses, and family size. It is determined on a monthly basis and can vary from person to person.
2. Monthly Obligation: Once the Share of Cost amount is determined, the individual must pay that amount out of their own pocket towards their medical expenses each month.
3. Eligibility for Medi-Cal: Once the individual’s medical expenses exceed the Share of Cost amount for that month, they are considered to have “met” their Share of Cost for that month. At this point, they become eligible for full Medi-Cal coverage for the remainder of the month.
4. Coverage Period: The Share of Cost and eligibility cycle resets at the beginning of each month. Any medical expenses paid in excess of the Share of Cost in a month do not carry over to the next month.

Example:

Let’s say an individual has a Share of Cost of $200. This means they need to pay the first $200 of their medical expenses themselves each month. Once they have paid $200 out of pocket, their Share of Cost for that month is considered met, and Medi-Cal coverage becomes effective, covering the remaining eligible medical expenses for that month.

Key Points:

• Share of Cost bridges the gap between having higher income levels and still needing financial assistance with medical expenses.
• It ensures that individuals are actively participating in sharing the costs of their healthcare.
• SOC applies to a wide range of medical services, from doctor visits to prescriptions to hospital stays.
• It’s important to keep track of medical expenses and ensure they exceed the Share of Cost to activate full Medi-Cal coverage for the month.
• The Share of Cost amount varies based on individual circumstances and is recalculated regularly.

In summary, Share of Cost is a mechanism used to determine an individual’s financial participation in their healthcare expenses before becoming eligible for full Medi-Cal coverage. It aims to strike a balance between affordability for the individual and sharing the costs of healthcare. Find out how ShareOfCost.com can help you meet your spend down needs for the California Share

 For a complete listing of specialty programs and hours of operation, please refer to the Medi-Cal Directory in the provider manual.

Mailing Address:
HP Enterprise Services
PO Box 13029
Sacramento, CA 95813-4029

Medi-Cal Fraud is Against the Law
Medi-Cal fraud costs taxpayers million each year and can endanger the health of Californians. Help protect Medi-Cal and yourself by reporting violations today.

DHCS Medi-Cal Fraud Hotline: 1-800-822-6222

The call is free and you can remain anonymous. Knowingly participating in fraudulent activities can result in prosecution and jail time. Help prevent Medi-Cal fraud.

Stop Illegal Tobacco Sales
The simplest way to stop illegal tobacco sales to minors is for merchants to check ID and verify the age of the tobacco purchasers. Report illegal tobacco sales to 1-800-5-ASK-4-ID.

For more information, see the California Department of Public Health – California Tobacco Control Web site.

In California, any transfer of a non-exempt asset (also called “countable”) within 30 months of an individual’s application for Medi-Cal for nursing facility level of care may result in a period of ineligibility. This period of ineligibility will only apply to the nursing facility level of care and, if
otherwise eligible, the individual would be eligible for all other Medi-Cal covered services. Remember, the look-back period does not apply to those assets that are exempt (also called “not countable”). The most common exempt asset is the individual’s principal residence. The period of ineligibility is determined by dividing the average private pay rate (APPR) in California, currently $4,322, into the value of the transferred non-exempt asset. Let us take a look at the following example:

Ten months prior to Ms. Peabody’s (a single individual) application to Medi-Cal to pay for her stay at Sunnyside Nursing Facility, she transferred $200,000 from her bank account to her son John. She meets all other eligibility requirements for Medi-Cal. Would Ms. Peabody have a period of ineligibility for payment to the nursing facility as determined by her eligibility worker? If so, what would be the period of ineligibility?

Yes, Ms. Peabody would have a period of ineligibility of 21 months. Here is how it is calculated:

The first step taken by the eligibility worker would be to determine the maximum period of ineligibility. This is accomplished by dividing the value of the $200,000 non-exempt transfer by the APPR for 2002, which is $4,322. For this example, the calculation results in 46 months. OBRA 93 (Omnibus Budget Reconciliation Act) lifted the ceiling on the maximum period of ineligibility. Remember, however, that the maximum period of ineligibility in California is still 30 months. In this example, the transfer took place 10 months prior to Ms. Peabody’s application for Medi-Cal. In determining the actual period of ineligibility, the eligibility worker would start counting beginning with the 10th month and continue through the 30th month. The ineligibility period would thus be 21 months. Medi-Cal would not begin to
pay for Ms. Peabody’s nursing facility costs until another 21 months had passed.

The period of ineligibility is always the lesser of one of the following: – 30 months; or – the number of months obtained by dividing the value of the transfer by the APPR; or – the difference between 30 months from the date of the transfer and the date of application for Medi-Cal benefits, inclusive. In other states, the look-back period and the period of ineligibility may differ from that used in California.

Currently, Medi-Cal does not pay for board and care in a RCFE, since RCFE care is not considered to be medical care. In addition, RCFE’s are not licensed as medical care providers. Medi-Cal does, however, allow an individual to retain income each month, up to the amount of the monthly charge of the facility, as long as the person requires and is receiving custodial care within the facility. If an individual is residing in an RCFE simply because the individual enjoys the luxury of not having to cook, clean and do laundry, Medi-Cal does not allow the individual to retain the additional income. If the individual is residing in the facility, however, because he or she requires assistance and needs custodial care, MediCal allows the individual to retain more of his or her income.

For example, a single individual residing in a RCFE receives $1,000 a month from Social Security and the RCFE charges $1,000 per month.

This individual would normally only be able to retain $600 per month because he or she is not residing in a hospital or intermediate or skilled nursing facility. Because he or she requires custodial care in an RCFE, the county allows the individual to retain $600 per month and considers the remaining $400 per month “unavailable” (similar to an income deduction) because the facility charge is $1,000 per month. This individual, then, has a zero share of cost and Medi-Cal pays all of the individual’s medical expenses
in that month for Medi-Cal covered services. If, however, the facility charges only $900 per month, the county will consider only $300 per month (in addition to the $600) as “unavailable”. In this case, the individual has a share of cost of $100 per month that he or she pays or obligates him or her to pay on medical expenses before Medi-Cal pays the remainder of Medi-Cal covered services.

The risk of esophageal cancer among patients who suffer from gastroesophageal reflux disease (GERD) is not as high as many may think, according to new research from University of Michigan gastroenterologists. GERD is considered a relative risk for developing esophageal adenocarcinoma, but the absolute risk is not known, says Joel Rubenstein, M.D., M.Sc.

There is no such thing as a Medi-Cal-friendly annuity. The balance of an annuity is considered unavailable as long as the owner receives equal monthly payments for a number of years, less than or equal to life expectancy (based upon life expectancy tables designated by Health Care Financing Administration for this purpose). The final payment may be smaller to exhaust the annuity. If payments are not equal and monthly, the cash surrender value is counted. If payments extend beyond life
expectancy, a period of ineligibility for nursing facility level of care may result. Some annuities pay very small amounts, with a balloon payment at the end. These annuities, even though set up to exhaust within life expectancy, are not annuitized in accordance with DHS rules. The cash surrender value is counted in determining eligibility. In many cases, these annuities are irrevocable and do not have a cash value and there is nothing to count. Individuals who purchase this type of annuity lose financial control while cashing in their life insurance policies, stocks, bonds, etc. Many times they have to pay heavy capital gains taxes and surrender penalties in the process.

The institutionalized spouse has $200,000 of assets protected through a Partnership policy. The spouse at home gives $200,000 to a child on January 1,1999, and applies for Medi-Cal on February 28, 2000. Is there a penalty under the rules for transfer of property?

In this example, assuming the couple has no other countable property (all they have is $200,000 in assets) at the time of the transfer, the transfer of the protected assets is considered a transfer of exempt property. Therefore, there is no period of ineligibility for nursing facility level of care. This above exemption only applies during the lifetime of the institutionalized spouse for eligibility purposes. After the institutionalized spouse dies, this exemption no longer applies. For estate recovery purposes, however, the $200,000 of asset protection continues even after the death of the protected spouse

The term “exempt” applies to a “type” or “classification” of property given exempt status by statute or regulation. Assets from a prior marriage are not a type of property that is exempt. Property from a prior marriage may be considered separate property if it has not been combined with the property of the current spouse. If the property is separate property, it may or may not be counted, as in the living situations described above. Estate recovery can file a claim against any asset (e.g., the community property interest) that passes from the deceased person to the surviving spouse upon his or her death. Estate recovery only takes place, however, when the surviving spouse dies.

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Patients with heart disease who also suffer from an anxiety disorder have a significantly higher risk of having a heart attack, heart failure, stroke and death, compared to other heart disease patients, according to Dutch scientists. You can read about this study in the peer-reviewed medical journal Archives of General Psychiatry

In the case of an inheritance, the assets disregarded for determining eligibility are the same as those in a pre-nuptial agreement. The estate recovery program can only file claims against the assets that pass from deceased Medi-Cal beneficiaries to their surviving spouses upon death. Any assets that pass to the surviving spouse before the death of the Medi-Cal beneficiary are not recoverable.

Degree Of Lifetime Stress Exposure Linked To Inflammation In Heart Disease

Greater lifetime exposure to the stress of traumatic events was linked to higher levels of inflammation in a study of almost 1,000 patients with cardiovascular disease led by researchers at the San Francisco VA Medical Center and the University of California, San Francisco.

A second pathway through which Alzheimer’s develops has been discovered after researchers identified a new set of genetic markers for the disease. Most Alzheimer’s genetic research focuses on amyloid-beta, which contributes to the formation of plaques found in the brains of people suffering from Alzheimer’s. In this study, published in the journal Neuron, researchers were able to identify genes linked to the tau protein, a protein which develops in the brain as Alzheimer’s slowly progresses.

With a prenuptial agreement, the county considers the living situation of the individual at the time of application in order to determine Medi-Cal eligibility. Let us take at look at three living situations: Example #1: Both spouses are at home. All non-exempt property over $3,000 (including assets
identified in a pre-nuptial agreement) is counted in determining Medi-Cal eligibility. Example #2: Both spouses are in board & care or only one spouse is in board & care and one remains at home or both spouses are in long-term care. The property of the non-applicant spouse that is established as separate property in the pre-nuptial agreement (as long as it remains
separate) is disregarded for purposes of establishing eligibility. Half of the community property is also disregarded.

The Medi-Cal “Look-Back” period in California is 30 months. “Transfer” means an outright gift or a “sale” made at less than “fair market value.” If a disqualifying transfer of property is made, Medi-Cal will calculate the period of ineligibility for nursing facility level of care. It will be the number of months resulting when the “net fair market value” of the transferred asset, which would have resulted in excess property at the time of the transfer, is divided by the monthly average private nursing facility cost. In 2002, the average cost used to calculate the period length is $4,322 per month. In 2001, this amount was $4,163.

Annuities are not considered exempt unless they are IRAs, KEOGHS, or work-related pension funds held in the name of a person who does not want Medi-Cal for him- or herself. If payments are being received, however, those payments are considered income. The cash surrender value of IRAs,
KEOGHS and work-related pension funds held in the name of an individual who does not want MediCal is counted until the individual takes steps to receive either the cash lump sum or periodic payments of principal and interest. The periodic payments are considered income and the balance is considered unavailable.

Nearly 88% of the 1,400 nursing homes in California accept Medi-Cal:
Title 18 only (Medicare): 8.3%
Title 18/19 (Medicare/Medi-Cal): 80.4%
Title 19 only (Medi-Cal): 7.3%
No Participation 4.0%