Who Is Eligible for Medi-Cal?

In short, Medi-Cal is a term used to represent the California Medical Assistance Program. The California Medical Assistance Program is California’s version of the Medicaid program. Medi-Cal is a California need-based program that offers health care benefits to low-income individuals, including:

• Families with children;
• Seniors;
• Persons with disabilities;
• Foster children;
• Pregnant Women; and
• Other low income individuals with specific diseases such as HIV, AIDS, breast cancer, or tuberculosis.

Medi-Cal is funded equally by California state taxes and federal funds. Importantly, not every California resident qualifies for or is eligible for the Medi-Cal program.

Who Is Eligible for Medi-Cal?

Once again, Medi-Cal is the state program that provides coverage based on an individual’s level of financial need. Disability is another key factor utilized in determining eligibility and coverage.

The following individuals or groups of individuals may qualify for Medi-Cal benefits:

1. Individuals Receiving Public Assistance: Individuals that receive public assistance, such as individuals who are 65 or older, are blind or disabled, or receive Supplemental Security Income (“SSI”) or State Supplementary Payment (“SSP”) may automatically qualify for Medi-Cal;
2. Individuals with Medical Needs: Individuals who are determined to be medically needy, such as disabled persons, or those who meet the family requirements of the California Work Opportunity and Responsibility to Kids (“CalWORKs”) program may receive Medi-Cal benefits;
3. Medically Indigent Individuals: Pregnant women without any access to public assistance programs, individuals between the ages of 21 and 65 that reside at a nursing facility, individuals under 21 years of age that receive public funds, or children who qualify for state assistance programs may qualify for Medi-Cal benefits; and/or
4. Individuals Under a Special Program: If an individual does not qualify for benefits based on one of the factors above, they may still qualify for benefits if they are:
   • A pregnant woman who cannot afford health care, even with their income;
   • Young children, including infants, and children aged 1 to 18 years of age;
   • Noncitizen victims of serious crimes that reside in California, such as victims of human trafficking;
   • Former children of the foster care program who have not reached 21 years of age, and were in foster care on their 18th birthday; and/or
   • Individuals receiving treatment for special diseases such as dialysis programs, breast cancer treatment, and cervical treatment.

What Are Other Factors Considered When Determining Medi-Cal Eligibility?

In general, the higher your income, the more you will have to pay towards your medical bills. Concerning assets, Medi-Cal caps the value of the assets an applicant may possess. However, the rules are complex, and certain assets may not be counted. Advanced planning with a qualified lawyer may be the best option.

What Is Medi-Cal Fraud?

In short, Medi-Cal fraud is simply any fraud that is committed in connection with California’s Medicaid program. Medi-Cal fraud is associated with the criminal acts of healthcare fraud and welfare fraud.

An individual may knowingly commit Medi-Cal fraud if they:

• Receive Medi-Cal benefits which they are not eligible for based on their false declarations;
• Make false declarations about another individual’s eligibility for Medi-Cal;
• Knowingly making a false or fraudulent claim for payment of a benefit under the Medi-Cal program; or
• Knowingly submitting a claim for a benefit under the Medi-Cal program that was not actually utilized by the claimant.

In addition to individuals utilizing the Medi-Cal program, health care providers may also be charged with Medi-Cal fraud if they:

• Present any false or fraudulent claim to the Medi-Cal program for services or merchandise that they did not actually perform or sell. For example, a Doctor that bills for an unnecessary procedures to Medicare using an inappropriate code in order to obtain a higher reimbursement with intent to defraud would likely charged with criminal Medi-Cal fraud;
• Knowingly submitting false information in order to obtain a greater compensation than that to which they are entitled from the services they performed under the Medi-Cal program. As noted above, Doctors may fraudulently bill the wrong code under the Medi-Cal program in order to receive higher compensation for that other procedure and code;
• Knowingly submitting false information to their clients for the purpose of obtaining authorization to provide health care services to patients covered by the Medi-Cal program. For example, a Doctor may provide a false diagnosis to a patient in order to provide services that they may be compensated for performing under the Medi-Cal program. If they do so then they will likely be found to have committed Medi-Cal fraud;
• Knowingly attempting or otherwise executing a scheme to defraud the Medi-Cal program, such as by using fraudulent statements or false representations to obtain payments or property from the Medi-Cal program; or
• Offering, soliciting, or receiving any bribes or kickbacks in return for patient referrals for Medi-Cal services or goods covered by the Medi-Cal program.

There are numerous examples which could cause an individual to be criminally prosecuted for Medi-Cal fraud, such as:

• An individual applying for Medi-Cal benefits, but not disclosing all of their income. For instance, an individual that withholds income they receive under the table or for the sale of goods, may be considered to commit Medi-Cal fraud for lying about their income on their application with the intent to defraud the Medi-Cal program;
• A physician that unnecessarily performs a procedure or bills for a different procedure other than the one they actually performed, may be charged with Medi-Cal fraud. For example, a dentist that performs an unnecessary extraction, or performs a filling, but then bills for a root canal, may be charged with Medi-Cal fraud; and
• A recipient of Medi-Cal benefits that submits fake receipts for reimbursements for medicine that they did not actually purchase or utilize, may also be charged with Medi-Cal fraud.

What Are the Penalties for Medi-Cal Fraud?

Typically, criminal charges for Medi-Cal fraud are wobblers. Most forms of Medi-Cal fraud are “wobblers.” In criminal law, the term “wobbler” refers to a criminal act that can be either punished as either a California felony or a California misdemeanor. The choice as to whether or not the accused defendant is charged as a felony or misdemeanor is typically made by the prosecutor at the time of charging the offense.

Criminal punishments for Medi-Cal fraud will be dependent on whether or not the individual is charged for a misdemeanor or felony. Potential felony punishments could include imprisonment for a period of time between one year and five years, fines of up to $50,000, or a combination of both. Additionally, the accused person may also be on the hook for double or triple of the amount that they defrauded the Medi-Cal program.

If the individual accused of Medi-Cal fraud is charged with a misdemeanor, then punishments could include imprisonment of up to one year in County jail, criminal fines of up to $10,000, or a combination of both.

It is important to note that an accused individual does have legal defenses that they can assert to have the charges brought against them reduced or dismissed. Although it may seem obvious, the main defense to a Medi-Cal fraud charge is that they did not act knowingly or with fraudulent intent. For example, a simply mistaken billing code may be forgiven and the charges brought against the accused could be dropped as they did not possess criminal intent.

Do I Need an Attorney For Help with Medi-Cal Eligibility?

As can be seen, applying for and receiving Medi-Cal benefits may be a complicated matter. Additionally, there are criminal penalties for any attempt to defraud the Medi-Cal program. If you have been accused of Medi-Cal fraud, you should immediately consult with an experienced healthcare attorney.

An experienced healthcare attorney will be able to help you determine if you are eligible for Medi-Cal benefits, as well as assist you in legally obtaining those benefits. Finally, they can also represent you in court if you have been wrongfully accused of Medi-Cal fraud.