How Does Medi-Cal Work in an Injury Accident in the Bay Area?

Applying for and getting signed up to Medi-Cal often raises many questions, especially in injury accident cases. Some of the commonly asked questions include; what does Medi-Cal cover? Do I have to pay back Medi-Cal? How does a settlement affect Medi-Cal? Does Medi-Cal have a lien? Etc. Let us see how an injury accident in the Bay Area affects Medi-Cal in the Bay Area.

What is Medi-Cal?

Medi-Cal is a public health insurance program in California that aids low-income families and individuals by offering free healthcare services. It is financed equally by state and federal governments. It caters to all low-income people, including:

People with disabilities
Pregnant women
Foster care
People affected by long-term diseases, etc.

Eligibility of Medi-Cal

Medi-Cal has a no discrimination process and is eligible for people of all ages regardless of their sex, religion, or race. There are over 90 eligibility categories of Medi-Cal. Once you fall in any one of them, you will be eligible for a full scale or partial scope of Medi-Cal. Here are some of the most common eligibility categories:

Everyone who qualifies for Supplemental Security Income (SSI) is eligible for SSI-Linked Medi-Cal
People who have a disability, are blind, or aged but have a high income that does not allow them to be Medi-Cal eligible may get a share of the cost for their medical expenses after spending a certain amount on them. This program is called Aged, Blind, or Disabled – Medically Needy Medi-Cal.
People who have a disability or are aged with low income may be eligible for Aged and Disabled Federal Poverty Level Medi-Cal.
Families who have an income below or at 138% of the Federal Poverty Level (FPL) may be eligible for Income-Based Medi-Cal. The percentage is 266% of FPL for children.
People who have a disability and are working must pay a small premium for Medi-Cal coverage before potentially being eligible for California’s Working Disabled Program.

Here is a summary of Medi-Cal’s eligibility categories: [1]

Income-Based
	Must have:	Low to moderate-income
	Income Limits:	For adults 19-64 years old – 138% of FPL For children 18 and under – 266% of FPL For pregnant women – 213% of FPL
	How Income is Counted:	All earned, and unearned income is counted based on IRS rules for adjusted gross income. No income is disregarded.
	Countable Assets Limits:	No limit
	Cost of Benefit:	Free
	Benefit:	Full-scope Medi-Cal
Aged & Disabled Federal Poverty Level
	Must Meet SSI’s definition of:	Age or disability
	Income Limits:	Countable Income less than $1,481 for individual, $2,004 for couples
	How Income is Counted:	SSI’s countable income calculation – MNA for number of household members not applying – health, vision, and dental insurance premiums
	Countable Assets Limits:	Up to $2,000 for Individual, $3,000 for couples
	Cost of Benefit:	Free
	Benefit:	Full-scope Medi-Cal
SSI-Linked
	Must Meet SSI’s definition of:	Age, blindness, or disability
	Income Limits:	Gross Income Less than SGA ($1,310 for individual, $2,190 if blind). Countable income less than the SSI/SSP benefit amount for your living situation
	How Income is Counted:	SSI’s countable income calculation
	Countable Assets Limits:	Up to $2,000 for individual, $3,000 for couples
	Cost of Benefit:	Free
	Benefit:	Full-scope Medi-Cal
Medi-Cal’s Working Disabled Program
	Must Meet SSI’s definition of:	Disability
	Income Limits:	Countable Income less than 250% of the Federal Poverty Level ($2,683 per month for individuals, $3,629 for couples)
	How Income is Counted:	SSI’s countable income calculation, but any disability income is not considered income
	Countable Assets Limits:	Up to $2,000 for Individual, $3,000 for couples; money in retirement accounts is not considered as an asset
	Cost of Benefit:	Sliding scale premium
	Benefit:	Full-scope Medi-Cal
Aged, Blind & Disabled – Medically Needy
	Must Meet SSI’s definition of:	Age, blindness, or disability
	Income Limits:	No income limit, but your countable income determines your share of cost
	How Income is Counted:	SSI’s countable income calculation – MNA for number of people in the household, including the applicant – health, vision, and dental insurance premiums
	Countable Assets Limits:	Up to $2,000 for individuals, $3,000 for couples, with an additional $150 per additional family member
	Cost of Benefit:	Share of cost
	Benefit:	Full-scope Medi-Cal

Remember, these are some of the many ways you can get Medi-Cal. You can talk to a Medi-Cal eligibility worker or visit a benefits planner to learn more about the other eligibility categories.

What Does Medi-Cal Cover?

Medi-Cal covers most of the necessary medical needs. You can ask your doctor or health plan if a service is covered or not. Some of the covered services include:

Outpatient services, such as routine doctors’ checkups
Intensive outpatient treatment, such as group counseling services
Laboratory services, such as blood tests
Physical therapy programs (habilitative and rehabilitative services)
Dentists’ appointments
Dental treatments and procedures
Vision care
Medical devices and supplies, such as oxygen tanks and wheelchairs
Residential treatment
Narcotic replacement therapy
Family planning
Prescription drugs
Mental health care
Drug or alcohol treatment
Hospitalization
Emergency services
Maternity and newborn care
Preventive and wellness services
Pediatric services
Other long-term benefits and support

How Does Medi-Cal Work in an Injury Case in the Bay Area

The Process of Lien

Suppose you are involved in a personal injury accident and are a Medi-Cal member. In that case, you or your personal representative is required by law to report the injury and the claim or action against the negligent party in writing. You have a period of 30 days after filing the claim, and you can send the notification by submitting an online form or through the mail.

The notification is required to include:

Your Medi-Cal identification number
The date of your injury
The liable third party or their insurer’s contact information
The claims administrator’s contact information and their claim number
The contact information of the defense counsel of the responsible third party or their insurer

After you notify Medi-Cal of your injury and claim, they check your Medi-Cal eligibility. If you are ineligible, they send you a ‘No Eligibility Letter.’ But if you are eligible, they create a personal injury case with them. They have a policy of 120 days passing from the final injury treatment date or the date of settlement (whichever occurs first). Still, often, a lien notice is sent to you before that, or your personal injury case may take longer than 120 days.

Furthermore, as a result of receiving a settlement against your personal injury, Medi-Cal will try to alleviate its responsibility of paying future medical and health bills on your behalf. For example, they often try to have you place the total or partial amount of the settlement in a trust so that it is secured to cover your future medical needs.

What to Do in Case of a Medi-Cal Lien?

Not just Medi-Cal, medical liens can be obtained by any party who pays for your medical bills in the case of a personal injury. So when you get the settlement, you find yourself facing a lien. A medical lien can be filed by your private insurance company (to which you have been paying premiums), your doctors or medical centers that provide you their services ‘on credit,’ or the public medical aid programs like Medi-Cal in the Bay Area.

These medical liens stand against your settlements and can often leave you with nothing or very little. To negotiate a reduced, void, or waived reimbursement, it is advised to hire a competent and experienced lawyer that can navigate your discussions with Medi-Cal.

You can negotiate with Medi-Cal for a compromised reimbursement, meaning it settles for an amount lower than what is being demanded. Using the claim number at the top of the written notice of lien, you can look at all the medical charges included in the lien notice. Look for any discrepancies or errors in the list keeping an eye out for:

Any amount that you have already paid or co-paid for
All the medical charges included in the lien should be related to the injury, and you should not include general medical services in it
Any charges stated twice or duplicated. Carefully check the dates, types of service, and the billed amount

Make sure you don’t mark the original copy of the lien. Also, don’t use a highlighter to mark the discrepancies you identify, as highlights often don’t show in photocopies. Underline the invalid or incorrect entries and send a copy to Medi-Cal to rectify the amount and keep a copy to yourself.

You can also base your negotiation on the fact that the reimbursement will cause you undue hardship. They may be willing to compromise if you can make a case for it. Some of the arguments in this regard are:

The settlement also accounts for your pain and suffering that is continuing
If you lost your job or wages due to the injury, the settlement would serve as bread and butter for you (and your family) until you find a job
You could need treatment due to a personal injury that Medi-Cal does not cover
If you get permanently disabled by the injury, the settlement will be required for your life-long care
Your treatments have not yet ended, and you still need the settlement money for them
If you have lost your normal life due to a personal injury accident, the settlement money will aid your rehabilitation
The settlement will help you get the mental health treatment required as a result of your personal injury accident

How Can a Lawyer Help Reduce the Medi-Cal Lien?

Personal injury lawyers are skilled and knowledgeable in personal injury accidents and the monetary implications attached to them. They know all the laws regulations, and if they are by your side, no one can double-cross you. As a result, they will not only get you a higher settlement against your personal injury claim but can also minimize, waive off, or void the Medi-Cal lien amount.

Remember, medical liens are very complex, and the state and federal laws attached to them are also problematic. Trying to figure out contract language, billing codes, and legal forms by yourself can be a mountainous task and unnerving when thousands of dollars are involved. However, experienced and able attorneys have many solved cases to back them. They know what, when, and how to say things to people and who to contact.

How Much is Pain and Suffering Worth in California?

There is no set rule or formula for calculating the worth of pain and suffering. To get awarded with a settlement that takes pain and suffering into account, you have to prove that you suffered from some kind of mental distress due to the accident. The factors that make your pain and suffering case stronger are:

If the physical injury is severe
The amount of economic losses is high
The evidence brought forward is strong
The defendant’s misconduct or recklessness is severe

In California, to receive pain and suffering awards, documented mental health symptoms are not required by law. However, your case will be stronger if you are diagnosed with one or more of the following illnesses:

Post Traumatic Stress Disorder (PTSD)
Anxiety
Insomnia
Depression
Other symptoms of emotional or mental illness

A competent and expert lawyer in the Bay Area will not only make sure that no action is taken against you while your personal injury case is up and running. Furthermore, they can save you vast sums of money by minimizing or voiding the lien amounts that will safeguard your and your family’s future.