Medi-Cal: California Medicaid Eligibility, Coverage, and Appeals

Medi-Cal is California’s Medicaid program, and it provides free or low-cost health coverage to California residents with limited income. Most adults qualify with an annual income under roughly $22,025 for a single person in 2026, and children qualify at significantly higher income levels.¹ Coverage runs from doctor visits and hospital stays to prescriptions, dental care, mental health treatment, and long-term care. The program is administered by the California Department of Health Care Services under Title 22 of the California Code of Regulations.²

Who Qualifies

Eligibility starts with California residency. You need to live in the state with the intent to stay, which is typically shown through a physical address on a utility bill, lease, or mortgage statement. From there, qualification turns almost entirely on monthly income.

Two changes in recent years reshaped who can get in. First, as of January 1, 2024, all income-eligible adults qualify for full-scope benefits regardless of immigration status. Citizens, permanent residents, and undocumented Californians are treated the same for eligibility purposes.³ Second, also as of January 1, 2024, California eliminated the asset limit for all Medi-Cal programs. Bank accounts, savings, a second vehicle, and property no longer count.⁴

Income Limits by Category

Most applicants are evaluated under the Modified Adjusted Gross Income (MAGI) standard. This applies to adults under 65 who are not blind or disabled, plus children and pregnant applicants. For most adults, the cutoff is 138% of the Federal Poverty Level. With the 2026 FPL set at $15,960 for a single person, that works out to about $22,025 per year, or roughly $1,835 per month.¹ Larger households qualify at higher dollar amounts because the FPL rises with each additional family member.

Children and pregnant applicants can qualify at higher income levels:⁵

Children ages 1 through 19 qualify up to 266% of FPL through the Optional Targeted Low-Income Children program.
Infants under age 1 qualify up to 208% of FPL.
Pregnant individuals qualify up to 213% of FPL for full-scope coverage.

At 266% of the 2026 FPL, a child in a single-parent household can qualify with family income up to roughly $42,450 per year.

Non-MAGI Medi-Cal uses a different evaluation process for people who are 65 and older, blind, or disabled. Income limits are generally lower for these groups, but the 2024 elimination of the asset test removed what had been the most common barrier for older adults with modest savings.⁴

What Medi-Cal Covers

Medi-Cal covers a broad set of health services. California has opted into nearly every optional benefit category federal Medicaid law makes available, which gives the program one of the most comprehensive benefit packages of any state Medicaid system.⁶ Covered services include:⁷

Primary and specialty care, including physician visits, outpatient clinics, and hospital services
Prescription drugs through Medi-Cal Rx, including up to a 100-day supply of many medications
Comprehensive preventive and restorative dental care for children and adults
Mental health and substance use treatment, including outpatient therapy, specialty mental health services, residential treatment, and detoxification
Vision exams and corrective lenses
Maternity care, from prenatal visits through delivery, postpartum care, and breastfeeding education
Physical, occupational, and speech therapy
Durable medical equipment such as wheelchairs, hearing aids, prosthetics, and orthotics
Home health services, including skilled nursing care and in-home support
Transportation to and from medical appointments
Emergency room visits and ambulance transport

Children under 21 receive even broader coverage through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires Medi-Cal to cover any medically necessary service for a child, even if that service is not part of the adult benefit package.

Most members receive care through managed care health plans rather than traditional fee-for-service. After enrollment, you are typically assigned to or asked to choose a plan in your county. The plan coordinates your care, assigns a primary care provider, and handles specialist referrals.

Types of Coverage Beyond Standard Full-Scope

Most enrollees receive full-scope Medi-Cal with no monthly premium. Several variations exist for people whose situation does not fit the standard mold.

Share of Cost. Applicants whose income slightly exceeds standard limits may still qualify through Share of Cost, which functions like a monthly deductible. You pay a set dollar amount toward your own medical bills each month before Medi-Cal starts paying. The county calculates your Share of Cost based on how much your income exceeds the program’s maintenance need level. You are not eligible for Medi-Cal benefits in any given month until that obligation is met through incurred medical expenses.⁸

250% Working Disabled Program. This program lets people with disabilities keep Medi-Cal while earning more than standard eligibility would allow. Net family income must fall below 250% of the FPL. The program originally required small monthly premiums, but a 2022 law reduced those premiums to zero for all participants.⁹

Home and Community-Based Services waivers. California operates several HCBS waiver programs for people who would otherwise need care in a nursing facility. Eligibility requires a determination that the person needs an institutional level of care, evaluated at enrollment and at least annually afterward. The waivers cover services like in-home supportive care, adult day health, and assisted living, giving people the option to stay in their communities rather than move into a facility.¹⁰

How to Apply

California uses the Single Streamlined Application, which also serves as the application for Covered California insurance and other public assistance programs.¹¹ You can submit it in several ways:

Online through the BenefitsCal portal at benefitscal.com, which handles Medi-Cal, CalFresh, and cash aid applications¹²
Online through the Covered California website, which routes you to Medi-Cal if your income qualifies
By mail or in person at your county social services office¹³

Gather your documents first: Social Security numbers for everyone in the household, proof of California residency, and income verification. A recent tax return or W-2 is ideal. If those are not available, 30 days of consecutive pay stubs will work. Self-employed applicants should prepare a profit and loss statement showing net monthly earnings.

State regulations require the county to decide within 45 days of receiving your application. If eligibility depends on a disability determination, the timeline extends to 90 days for medical record review.¹⁴ When the decision is made, you receive a Notice of Action in the mail. Keep it. That notice is your official record and contains the information you need if you want to appeal.

If You Need Care Before Approval

Two features of Medi-Cal help if you need medical care immediately or already have bills from before you applied.

Hospital Presumptive Eligibility lets qualified hospitals grant temporary Medi-Cal coverage on the spot, based on self-reported income and household size. No pay stubs or tax returns are required at that point.¹⁵ Under federal rules, if you do not submit a full Medi-Cal application, the temporary coverage ends on the last day of the following month. If you do submit an application by that deadline, coverage continues until your application is approved or denied.¹⁶

Retroactive coverage works differently. Medi-Cal can pay for services you received during the three months before the month you applied, as long as you would have been eligible at the time.¹⁷ If you paid out of pocket during that window, you can request reimbursement after enrollment.

Keeping Your Coverage

Medi-Cal eligibility is not permanent. Each year the county must verify that you still meet the income and residency requirements. The process begins with an “ex parte” review, where the county checks electronic databases and information from other public assistance programs to confirm eligibility automatically.¹⁸ If the databases confirm everything, your coverage renews without any action on your part.

If the county cannot verify your information electronically, it mails a renewal form. You have to complete and return it with updated income information, or your coverage will end. The county cannot take a negative action like discontinuing benefits or adding a Share of Cost based only on an ex parte database check without first giving you the chance to respond.¹⁸

If your coverage is terminated because you did not respond, you have a 90-day cure period to submit the paperwork. Do so and, if you still qualify, benefits are reinstated retroactively to the date of discontinuance. Outside the annual renewal, you must report changes in household circumstances (a new job, a change of address, a change in family size) within 10 days of the change.¹⁹

If Your Application Is Denied or Benefits Are Cut

If Medi-Cal denies your application, reduces your benefits, or terminates coverage, you have the right to request a State Fair Hearing. Federal regulations give you up to 90 days from the date the Notice of Action is mailed to file.²⁰ The hearing request form is usually included with the notice. You can also request one by calling the California Department of Social Services State Hearings Division or submitting a written request by mail.

If you already have Medi-Cal and the state plans to reduce or end coverage, timing matters. To keep benefits running while your appeal is decided (known as “aid paid pending”), you have to file your hearing request before the effective date of the change, which can be as few as 10 days after the notice is mailed. Miss that window and benefits stop while the appeal is processed. One risk to consider: if you receive aid paid pending and then lose the appeal, the state may require you to repay the cost of services received during the appeal period.²¹

Long-Term Care and Estate Recovery

Two rules matter especially for older adults, spouses, and families thinking about long-term care.

Spousal impoverishment protections. When one spouse needs nursing facility care through Medi-Cal and the other stays in the community, federal and state law let the community spouse keep a portion of the couple’s combined assets, called the Community Spouse Resource Allowance. For 2026, the maximum CSRA in California is $162,660.²² The community spouse also retains a monthly income allowance for basic living expenses. Nursing facility residents on Medi-Cal are typically allowed to keep only a small personal needs allowance from their monthly income, with the rest going toward the cost of care. The 2026 SSI Federal Benefit Rate of $994 per month is an important benchmark in these calculations.²³

Estate recovery after death. California’s Medi-Cal Estate Recovery Program allows the state to seek reimbursement for certain medical costs paid on behalf of a member after that member dies. Under current law, the state can recover only in two situations:²⁴

For nursing facility patients of any age, recovery applies to the cost of nursing facility care.
For members who were 55 or older when they received services, recovery can include a broader range of health care costs.

California has deliberately limited estate recovery to what federal law requires. The Legislature stated its intent to restrict recovery to services federal law compels the state to collect and to define “estate” as narrowly as federal law permits.²⁴ Recovery is limited to the probate estate. Assets held outside probate, such as property in a living trust or assets passing through joint tenancy, are generally protected.

Recovery is completely prohibited if the deceased member is survived by any of the following:²⁴

A spouse or registered domestic partner
A child under age 21
A child who is blind or disabled

Even when none of those protections apply, the state must waive its claim if enforcement would cause substantial hardship to other dependents, heirs, or survivors. The statute directs the Department of Health Care Services to waive recovery when the estate is a homestead of modest value.²⁴

1
Federal Register. Annual Update of the HHS Poverty Guidelines
2
Legal Information Institute. California Code of Regulations 22 CCR 50005 – Medi-Cal Regulations
3
Medi-Cal. Ages 26 Through 49 Adult Full Scope Medi-Cal Expansion
4
Los Angeles County Department of Public Social Services. Medi-Cal Asset Elimination Frequently Asked Questions and Answers
5
Department of Health Care Services. Program Descriptions by FPL Enclosure 3
6
Medicaid.gov. Mandatory and Optional Medicaid Benefits
7
Department of Health Care Services. Medi-Cal Benefits Chart
8
Medi-Cal. Share of Cost (SOC) – Medi-Cal Providers
9
Department of Health Care Services. Working Disabled Program
10
eCFR. 42 CFR Part 441 Subpart G – Home and Community-Based Services Waiver Requirements
11
Department of Health Care Services. SSApp Update
12
BenefitsCal. Home – BenefitsCal
13
Department of Health Care Services. Apply for Medi-Cal
14
Santa Clara County Social Services Agency. Medi-Cal Handbook – Timeframes for Processing Applications
15
Medi-Cal. Hospital Presumptive Eligibility (HPE)
16
Medicaid.gov. MACPro Implementation Guide – Presumptive Eligibility by Hospitals
17
Department of Health Care Services. Medi-Cal Reimbursement Request
18
Department of Health Care Services. Medi-Cal Eligibility Division Information Letter No I 23-49
19
Department of Health Care Services. Align Medi-Cal Redeterminations with Federal Guidelines Fact Sheet
20
eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
21
Medicaid.gov. Medicaid Fair Hearings and Appeals – A Partner Resource
22
Department of Health Care Services. County Welfare Directors Letter No 26-02
23
Social Security Administration. SSI Federal Payment Amounts for 2026
24
California Legislative Information. California Code WIC 14009.5