Medi-Cal and Medicare Dual Eligibility

What Is Medi-Cal and What Does It Cover?

The name sounds a lot like Medicaid for good reason. Medicaid is a federal program, but the details of coverage are handled by each individual state. Underneath the Medi-Cal name lies California’s version of Medicaid. And like other Medicaid programs around the country, Medi-Cal offers low-income individuals and families financial relief in paying for medical expenses. The program also covers people who are blind or disabled, as well as children under 21 years old, pregnant women, parents or caretakers of qualifying children, and people who qualify for Medicare.

Here’s a look at some of the benefits Medi-Cal offers:

• Emergency care – this includes coverage for expenses related to hospital stays, as well as help paying for the emergency services rendered.
• Outpatient services – this benefit covers doctor’s appointments, specialist’s appointments, dental care and more.
• Mental health care – Medi-Cal’s mental health benefits coverage for behavioral healthcare, including addiction and substance abuse treatment.
• X-Rays and lab tests
• Certain preventive care – this includes certain wellness services
• Pediatric care
• Long-term care – this category also includes hospice care
• And much more

All of the eligible services and medical equipment covered by California’s Medicaid programs are considered “medically necessary.”

How Can Medi-Cal and Medicare Dual Eligibility Save You Money?

The level of need per individual or household varies, so California’s Medicaid program doesn’t offer full coverage to everyone who’s eligible for the program. Those who are eligible for both Medicare and Medi-Cal, known as dual eligible*, may qualify for full coverage from Medi-Cal.

Medicare and Medi-Cal dually eligible individuals stand to save much more than people who are eligible for one program or the other. Yet, there are many people who are completely unaware that they qualify for both programs and the relief these programs could be providing them.

Medi-Cal will help cover the costs of Original Medicare (Part A and Part B) for dually eligible people who qualify for full coverage from California’s Medicaid program.

Here’s a quick overview of what Original Medicare includes, as well as what Medi-Cal will pay for:

• Part A (inpatient hospital care and emergency services) – Medi-Cal will pay for your Part A deductibles and copays. If you’ve contributed to Medicare through payroll taxes, you could get Part A premium-free or at a reduced rate.
• Part B (outpatient care, including doctor’s visits) – Medi-Cal will pay your Part B deductibles, copays and monthly premiums.

*California resources may also use the term “Medi-Medis.”

What Does it Take to Qualify as Dually Eligible for Medi-Cal?

In the state of California, dually eligible individuals have to qualify for Medicare and Medicaid separately. In some states, the bar for dual eligibility may include additional requirements beyond simply qualifying for each program separately.

So, what does it take to qualify for Medicare? And what does it take to qualify for California’s Medicaid program? Here’s an overview of what it takes to join each health program:

Medicare requirements – You have to be a U.S. citizen or permanent resident age 65 or older, OR under age 65 and you have been receiving Social Security Income for at least two years.

Medi-Cal requirements – The minimum requirements for Medicaid in California are a monthly income that falls within 123% of the federal poverty line for California and individual assets totaling less than $2,000. The asset count does not include your primary home, one vehicle, certain amounts of life insurance, prepaid burial plans, and burial plots. Requirements may be different for couples.

Even if you don’t quite meet the minimum requirements for Medi-Cal, you may still qualify for some benefits. Those who qualify for Medicare and limited help from Medi-Cal are categorized as partial dual eligible, a designation that could still help you save a significant amount of money on healthcare expenses.

Medicare and Medi-Cal Dual Eligible Enrollment: Selecting Coverage

Between Original Medicare, Medicare Advantage and Medi-Cal, there are dozens of plans to choose from and many more configurations of those plans to exponentially expand your options for coverage. But in general, there are three primary configurations dual eligible people in California can select from to maximize both their healthcare coverage and savings.

Medi-Cal, Original Medicare and Medicare Part D

In this configuration, Medi-Cal helps you pay for Medicare’s emergency care (Part A) and outpatient care (Part B). You also get prescription drug coverage (Part D) and automatically qualify for help paying for your prescriptions through Extra Help. Medicare pays first for any medical expenses, but Medi-Cal can help pay for services Medicare doesn’t cover – such as vision and dental care.

Medi-Cal and Medicare Advantage

Like the above configuration, Medi-Cal helps pay for emergency care (Part A) and outpatient care (Part B) through Medicare. You would be automatically eligible for Extra Help if your coverage includes a prescription drug plan through Medicare. While Medi-Cal’s plan offers expanded coverage on its own, you could also use this combination of coverage to secure a premium Medicare Advantage plan that may offer even more coverage. These are called Dual Special Needs Plans (D-SNPs) and they are specifically designed to provide the coverage and costs savings that dually eligible individuals may need.

Cal MediConnect (CMC)

Managing a chronic condition or lingering medical issue can consume a lot of your time, making it difficult to stay on top of handling your Medicare and Medicaid coverage. California’s Cal MediConnect is a coordinated care plan that helps simplify things by taking much of the work out of your hands and placing it into the palms of a care coordinator. Your care coordinator can help you select the right coverage, schedule appointments, manage medications and much more.

Keep reading for answers to common questions about Medi-Cal and Medicare, as well as additional resources.