Living on $600 a month? Seniors over income limit can struggle to afford Medi-Cal

Month by month, the savings that Rosaline George scraped together in her years as a journalist and local government employee have been dwindling as the 97-year-old pays out of pocket for hourly care.

“Without a caregiver,” she said, “I would be dead in two days.”

Getting onto Medi-Cal, the California Medicaid program, could be her gateway to a program that pays for home caregivers. But George learned that to do so, she would have to spend most of her Social Security check on medical expenses, leaving her just $600 a month to survive in her Hollywood apartment.

In California, elderly or disabled people making too much to qualify for Medi-Cal can still access the program if they pay a “share of cost” toward their medical bills. But advocacy groups argue the rules are so restrictive that many Californians who need such help are shut out — and they’re making a fresh push to change it.

California calculates the amount that seniors like George must fork over by taking their monthly income and subtracting a fixed amount on which they are supposed to survive, called a “maintenance need income level.”

“Without a caregiver, I would be dead in two days,” Rosaline George, 97, says.

(William Liang / For The Times)

That maintenance amount has been set at $600 a month for a single adult since 1989 — an amount that would be more than $1,500 in today’s dollars.

That means that even if someone is just barely over the income limit for Medi-Cal, which is now $20,783 annually for a single adult, getting coverage requires them to spend so much on medical care in a given month that they have only $600 left for other expenses such as rent, utilities and food.

Among people who are not living in nursing facilities, only a small fraction of seniors and disabled people trying to get “share of cost” Medi-Cal — 8% — spent enough on medical expenses to meet the requirement in January 2023, according to the most recent data available from the state.

“It’s really punishing for people,” said Tiffany Huyenh-Cho, the California director of Medicare and Medicaid advocacy for Justice in Aging, one of the groups that has pushed to change the requirements. “Six hundred dollars today is just not enough to live on.”

Older adults are typically insured through Medicare, but unlike Medi-Cal, it does not broadly cover the kind of home care that many Californians need as they age. Even for people who are beyond the income limits for Medi-Cal, however, paying for home care themselves can be prohibitively expensive.

The result is that many families shoulder the work themselves, losing out on paid employment, or elderly people scrimp on needed assistance. Advocates argue that going without such support can jeopardize their health and ultimately leave them in need of more costly care in institutional settings.

Out-of-pocket spending on home care could count toward the required monthly “share of cost” to get Medi-Cal, but that care must be prescribed by a clinician under specific circumstances, Huyenh-Cho said. Advocates said trying to submit such expenses can be so logistically complicated that it is unworkable.

In Hollywood, George said that she receives less than $2,900 a month through Social Security — a modest income but significantly above the Medi-Cal cutoff. Advocates told her that based on that income, she must spend more than $2,200 a month on medical expenses to qualify for Medi-Cal.

There are ways to reduce and even eliminate that cost-sharing requirement, but they require spending. When George turned to the legal advocacy group Bet Tzedek for help, the group suggested she could purchase supplemental health insurance to bring down her “countable income.”

“I said, ‘Just a minute, are you telling me to get rid of some of my Social Security benefits?’” George recounted. “And they said, ‘That’s what Medi-Cal is saying.’”

Buying supplemental health, vision or dental insurance can bring down the amount of income that is counted for the Medi-Cal program, allowing people to avoid paying a share of cost. In the San Francisco area, one family resorted to spending more than $2,100 a month on such added insurance to help a 93-year-old woman access Medi-Cal and its home care program.

“Quite frankly, I think it’s crazy,” said Jaime, whose mother, Maria, needs round-the-clock care after suffering a stroke. The family asked not to use their last names to protect her privacy. Maria retired as the longtime owner of a diner and her Social Security checks and her husband’s pension put her over the Medi-Cal income limit.

Buying extra insurance costs more than half of her monthly income of under $4,200, but Maria would otherwise have to spend roughly $3,600 each month on medical expenses to be eligible for Medi-Cal.

“The way I see it, the function is to get rid of the share of cost,” Jaime said of the money they spend on supplemental insurance. “Otherwise, my mother gets zero benefit from purchasing that insurance.”

Two years ago, California state officials agreed to change the $600-a-month allocation for other needs to match 138% of the federal poverty level. (That figure, which changes annually, is the same one California generally sets as the income limit for Medi-Cal.) This year, that would amount to over $1,700 a month.

The new level was supposed to go into effect in January 2025, but the plan was jettisoned amid a state budget deficit. Groups that advocate for the elderly and disabled are now asking the state to make it happen in 2026.

In an October letter, Justice in Aging and other advocacy groups asked Gov. Gavin Newsom to allocate $33 million from the general fund in the next budget year and $80 million annually thereafter. In the past, state analysts had estimated the costs of the proposed change from $53 million to $151 million annually, half of which would be covered by federal funds.

A Newsom spokesperson said his office was “unable to speculate” on what the governor might include in his upcoming budget for the fiscal year of 2025-26. Health policy experts anticipate that federal funding for Medicaid programs could be cut after President-elect Donald Trump takes office for a second time, which could put more strain on California to use its state dollars to maintain its existing programs under Medi-Cal.

Dozens of states have “medically needy” options for their Medicaid programs like California. “The key to these programs is they’re for people who are low-income after considering their spending on healthcare,” said Alice Burns, associate director of the Program on Medicaid and the Uninsured at KFF, an independent health policy research, polling and news organization.

“A person has to document all of their healthcare spending and show that ... it has brought their income below the medically needy limit,” which can be complicated process, Burns said.

George, who before her retirement worked part-time on issues surrounding aging for an L.A. County supervisor, said that meeting her basic needs as a 97-year-old shouldn’t require her to give up her Social Security income, benefits “that President Roosevelt gave to us.”

“They are telling me, ‘Too bad. You’re too rich,’” George said. But what is she supposed to do, she asked, when her savings have dried up?

“My caregivers won’t work if I can’t pay them.”