Medi-Cal Fraud: Obtaining Benefits Through False Representation (WIC 14014)

California Welfare and Institutions Code 14014 (WIC 14014) makes it a crime to obtain or attempt to obtain Medi-Cal health care benefits by making false declarations.

When an individual provides misleading information to obtain services for which they're not eligible, they face significant legal consequences, including mandatory repayment of benefits, civil damages, and criminal prosecution, which may result in up to 3 years in prison, depending on the value of the benefits they falsely received.

The State of California aggressively prosecutes instances of Medi-Cal fraud.

If you are under investigation for a violation or have already been charged, our California criminal defense attorneys can act on your behalf to defend your innocence and/or minimize the risks of severe penalties.

Call Eisner Gorin LLP at (818) 781-1570 or use our contact form.

What Is Considered Illegal Under WIC 14014?

Under WIC 14014, it is a crime to knowingly make false statements or provide false information to the government to establish eligibility for health care services to which an individual is not entitled.

It's a form of Medi-Cal Fraud that can be prosecuted as a misdemeanor or felony.

To secure a conviction, the prosecution must prove that the defendant intentionally deceived the state to receive benefits. This deception typically occurs during the application or recertification process.

How Does California Define a “False Declaration” in Medi-Cal Cases?

Under California law, a false declaration is a formal statement, made willfully and knowingly to the government, that is materially untrue.

The core of a WIC 14014 violation lies in the "declaration." This legal term refers to the formal statement of facts provided to the government agency administering the program. Common examples of false declarations include:

Misrepresenting Income or Assets: An applicant might underreport their earnings or fail to disclose bank accounts and property to appear below the financial threshold for eligibility.
Household Composition: Falsifying the number of people living in the home or claiming dependents who do not actually reside there can artificially lower the household's per-capita income calculation.
Residency Status: Providing false information about California residency status is a frequent basis for fraud allegations, as Medi-Cal is reserved for state residents.
Failure to Report Changes: Fraud is not limited to the initial application. Failing to report a significant change in circumstances—such as a new job, an inheritance, or a change in marital status—that would affect eligibility can also constitute a false declaration by omission.

Who Can Be Prosecuted for Making False Declarations for Medi-Cal Benefits?

WIC 14014 applies to:

A person receiving benefits based on their own false statements;
Someone making false statements on behalf of another; and
Someone who encourages another to make false statements.

While the law applies directly to the person receiving the benefits, it also extends liability to any person who makes false declarations on behalf of another individual.

This means that a parent filing for a child or a caregiver filing for an elderly patient can be held criminally liable if they provide false information to secure benefits for that third party.

Furthermore, under WIC 14014(b), it is illegal to willfully and knowingly counsel or encourage another person to make false statements on a Medi-Cal application.

This provision is significant because if you advise someone to omit income on their application so they can qualify, you may be held financially responsible for the cost of the services they subsequently receive.

Is Medi-Cal Fraud Charged as a Misdemeanor or Felony?

Making false declarations on a Medi-Cal application may be charged as a misdemeanor if the total value of the benefits obtained is less than $950, or as a felony if the value exceeds $950.

Under California law, making false statements to obtain Medi-Cal benefits is prosecuted as theft under California Penal Code 487 and 488.

The prosecutor will calculate the specific dollar amount of the medical services, prescriptions, and premiums paid by Medi-Cal on the defendant's behalf during the period of ineligibility.

Misdemeanor (Petty Theft): If the total value of the benefits received is $950 or less, the offense is typically charged as a misdemeanor.
Felony (Grand Theft): If the value of the benefits exceeds $950, the offense qualifies as grand theft. This is a "wobbler" offense in California, meaning the prosecutor has the discretion to charge it as either a misdemeanor or a felony. However, in cases involving substantial sums, felony charges are common.

In these cases, the calculation of value over time is critical. Since Medi-Cal benefits are often received incrementally (a doctor visit here, a prescription there), Penal Code 487(e) allows prosecutors to aggregate the value of benefits obtained over a 12-month period.

This rule means multiple small instances of fraud, each under the $950 threshold, can be combined into a single grand theft charge. For instance, receiving $100 in benefits monthly for a year based on a false application would exceed $950, exposing the applicant to felony charges.

What Are the Penalties for Medi-Cal Fraud Under WIC 14014?

If you're convicted of Medi-Cal Fraud under WIC 14014, you could face up to 6 months in county jail for a misdemeanor offense, or up to 3 years in prison for a felony.

A conviction for Medi-Cal fraud can result in a combination of criminal penalties, including jail or prison time and fines, as well as civil liabilities such as full repayment of benefits and additional damages.

The criminal penalties vary based on how the crime is charged:

Misdemeanor Conviction: If convicted of a misdemeanor, you face up to 6 months in county jail. Additionally, the court may impose fines up to $1,000.
Felony Conviction: For a felony conviction, you may face sixteen months, two years, or three years in state prison (served in county jail under AB 109 realignment). Fines can reach up to $10,000.

In addition to these penalties, you could face additional civil fines and be required to pay back the government for the value of the benefits you took unlawfully.

Related California Crimes

Welfare Fraud – Welfare and Institutions Code 10980

Welfare fraud under WIC 10980 occurs when someone knowingly provides false information to obtain public assistance benefits such as CalWORKs, food assistance, or other government aid. Like Medi-Cal fraud, the offense can be charged as either a misdemeanor or a felony, depending on the value of benefits obtained.

If the value exceeds the statutory threshold, prosecutors may pursue felony charges that carry potential jail or prison time, restitution orders, and fines.

Insurance Fraud – Penal Code 550

Insurance fraud involves knowingly submitting false claims or misleading information to an insurance company to obtain payments or benefits. In the healthcare context, this may include billing insurers for services that were never provided or falsifying medical documentation.

Insurance fraud is typically prosecuted as a felony in California and can result in significant prison sentences, fines, and restitution.

Grand Theft – Penal Code 487

Grand theft occurs when someone unlawfully takes property or benefits valued at more than $950. In Medi-Cal fraud cases, prosecutors frequently use the grand theft statute when the total value of benefits received through false declarations exceeds the threshold amount.

Grand theft is a “wobbler” offense, meaning it can be charged as either a misdemeanor or a felony depending on the facts of the case and the defendant's criminal history.

False Statements to Obtain Public Benefits – Penal Code 118 and Related Statutes

Providing knowingly false statements to a government agency may also lead to additional charges. These charges typically involve signing or submitting documents containing false information under penalty of perjury.

If the prosecution proves that the defendant intentionally made false statements in official documents, the offense may be prosecuted as perjury or fraud-related conduct.

Conspiracy – Penal Code 182

If two or more people agree to commit Medi-Cal fraud and take steps to carry out the plan, prosecutors may file conspiracy charges. Conspiracy does not require the crime to be completed; the agreement and an overt act toward committing the offense are enough.

Conspiracy charges can significantly increase potential penalties in fraud investigations.

Forgery – Penal Code 470

Forgery occurs when someone alters, creates, or uses a false document in order to commit fraud. In Medi-Cal investigations, this may involve falsified income records, fake identification documents, or altered financial statements used during the application process. Forgery can be prosecuted as either a misdemeanor or a felony.

Frequently Asked Questions

What is Medi-Cal fraud under California law?

Medi-Cal fraud occurs when a person knowingly provides false information or conceals important facts in order to obtain government healthcare benefits they are not eligible to receive. This commonly occurs during the application process or when recipients fail to report changes that affect eligibility.

Is Medi-Cal fraud a felony in California?

It depends on the value of benefits obtained. If the value of benefits is $950 or less, the offense is typically charged as a misdemeanor. If the value exceeds $950, prosecutors may charge the offense as felony grand theft.

Can someone go to jail for Medi-Cal fraud?

Yes. A misdemeanor conviction can result in up to six months in county jail, while a felony conviction can carry a sentence of up to three years in custody, along with fines and restitution.

Do I have to repay benefits if I'm accused of Medi-Cal fraud?

In most cases, the government will seek repayment of the value of benefits that were allegedly obtained improperly. Civil penalties may also be imposed even if criminal charges are reduced or dismissed.

What if I made a mistake on my Medi-Cal application?

Mistakes or misunderstandings do not automatically constitute fraud. Prosecutors must prove that the defendant knowingly and intentionally provided false information. If the error resulted from confusion or misunderstanding, criminal liability may not apply.

How are Medi-Cal fraud investigations started?

Investigations often begin after audits, data reviews, or reports from government agencies. The Department of Health Care Services, local district attorneys, and the California Department of Justice may investigate suspected fraud.

Can Medi-Cal fraud charges be reduced or dismissed?

Yes. Depending on the evidence, defense attorneys may challenge the government's proof of intent, dispute the calculated value of benefits, or negotiate diversion programs, restitution agreements, or reduced charges.

Should I speak with investigators if I'm accused of Medi-Cal fraud?

It is generally best to consult with a criminal defense attorney before speaking with investigators. Statements made during an investigation can be used as evidence in court.

How Can an Attorney Defend Me Against Medi-Cal Fraud Allegations?

A skilled California criminal defense attorney can challenge Medi-Cal fraud allegations by scrutinizing the prosecution's evidence, proving a lack of fraudulent intent, or demonstrating that mistakes were made without a deliberate effort to deceive.

Because fraud requires specific intent, there are several avenues for a solid defense, including:

Lack of Intent: The prosecution must prove you knowingly and willfully made false declarations. Medi-Cal applications are often complex and confusing. A strong defense can argue that inaccuracies were unintentional, caused by misunderstanding or simple oversight.
No False Declaration: The defense may argue that the information provided was accurate at the time of the application. This involves presenting evidence like pay stubs, lease agreements, or tax returns to verify claims about income, residency, or family status.
Mistake of Fact: This defense applies if you genuinely believed you were eligible for benefits, even if mistaken. For instance, if advice led you to believe certain assets were exempt from reporting, this mistake could negate criminal intent.
Challenging the Value: A defense attorney will closely review the prosecution's calculation of "loss," often based on inflated "market rates." If the proven value of benefits is reduced below $950, a felony charge could be downgraded to a misdemeanor, lowering the possible penalties.

Recent Case Study

Through pretrial diversion, we successfully negotiated the dismissal of fraud charges for one of our clients.

What Do I Do if I'm Accused of Medi-Cal Fraud?

If you're charged with violating WIC 14014, you should contact a skilled California criminal defense attorney with experience in fraud cases as soon as possible.

Medi-Cal fraud under WIC 14014 is a serious offense with consequences that extend beyond simple repayment.

The charge is directly tied to California's fraudulent insurance claims laws, and a conviction can lead to incarceration, substantial financial penalties, and a permanent criminal record.

With this much at stake, your best hope of avoiding the worst consequences is with the help of an experienced attorney.

At Eisner Gorin LLP, our legal team is highly experienced in navigating complex fraud charges, including Medi-Cal fraud. We employ a comprehensive defense strategy to ensure you have the best chance of a favorable outcome.

If you're facing charges, call us right away at (818) 781-1570 or use our contact form for a confidential case evaluation.

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