Medi-Cal vs. Medicare: Who’s Eligible & What’s Covered?
Medi-Cal vs. Medicare: Who’s Eligible & What’s Covered?
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Medi-Cal provides health care coverage to those in California who have a low income, while Medicare is a nationwide program that covers seniors and those with certain disabilities.
Eligibility for Medi-Cal is based on income. In most circumstances, you’ll qualify for Medi-Cal's free coverage if you’re an individual earning $20,120 or less a year or a family of four making $41,400 or less annually. If you earn more, you may still qualify and can have a small monthly cost.
In contrast, Medicare has no income or state residency requirements. You qualify when you turn 65 or if you have a qualifying disability. If you meet the eligibility requirements for both programs — for example, turning 65 and having a low income — you can be dually enrolled in both Medi-Cal and Medicare.
What is the difference between Medicare and Medi-Cal?
Medi-Cal and Medicare are two separate and distinct programs, each driven by its own mission and each playing a vital role in providing health care to its respective population.
As a Medicaid program, Medi-Cal serves as a health care safety net, paying the medical expenses for beneficiaries who have low incomes. This can include individuals, families, children and those who are pregnant, as well as seniors and people who have disabilities. With Medi-Cal, you have to meet certain income requirements, a condition not required by Medicare.
Medicare, by contrast, is a federal program that operates on a nationwide basis, providing health care coverage to more than 63 million seniors and disabled beneficiaries under the age of 65.
|Eligibility||Individuals and families who have low incomes and/or certain health conditions||Seniors age 65+ and individuals with certain disabilities|
|Coverage||Medical care, hospitalization, prescription drugs, long-term care nursing homes and extended stays in skilled nursing facilities||Coverage varies by the part of Medicare and can include medical care, hospitalization and prescription drugs. Usually, no coverage for long-term care and extended stays in skilled nursing facilities.|
|Cost||Free to low-cost based on the Medi-Cal program (usually cheaper than Medicare)||Typically, a few hundred dollars per month. Plus, there are costs for medical care and prescriptions including copays and deductibles.|
|Program administrator||The California Department of Health Care Services (state of California)||Department of Health & Human Services (federal government)|
|Program funding||A combination of state and federal funds||Primarily funded by the federal government|
|Individual and/or family coverage||Both individuals and family members can be covered if they meet the program requirements||Coverage is only for individuals and does not extend to other family members|
|Components||Several comprehensive initiatives with different eligibility criteria||Four separate parts — A, B, C and D — with each focusing on one or more areas of care such as hospitalization or prescriptions|
What is Medi-Cal, and who’s eligible?
Medi-Cal provides free and low-cost health benefits to more than 14 million low-income beneficiaries in California.
Like other state Medicaid programs, Medi-Cal requires residents to qualify by meeting certain income or health status requirements or a combination of both.
Medi-Cal enrollees receive comprehensive health services, covering inpatient and outpatient care, including extended stays in skilled nursing facilities and long-term care in nursing homes — services not generally covered by Medicare. Medi-Cal also covers vision and dental care, which aren't covered by Original Medicare.
The most common form of Medi-Cal is based on modified adjusted gross income (MAGI), so it relies on taxable income to determine eligibility.
Because California has expanded its Medicaid program, Medi-Cal uses 138% of the federal poverty level (FPL) as the maximum income to qualify for some, but not all, of the programs that comprise Medi-Cal.
When qualifying in this way, the size of your household will affect the maximum income you can earn. For an individual, earning 138% of the federal poverty level or less means you can earn a maximum of $20,120 per year to qualify. For a family of four, you’re eligible for Medi-Cal if you earn up to $41,400 per year.
Income limit for Medi-Cal eligibility
While 138% of the federal poverty level is the general guideline, it does not apply to everyone. For example, those who are pregnant can qualify for Medi-Cal more easily because they have a higher income limit for eligibility at 213% of the federal poverty level or $31,055 annual income for an individual.
Medi-Cal also has several smaller programs that operate within the larger Medi-Cal program. These may use non-MAGI criteria that take into consideration assets, household income and household size to determine eligibility for adults.
One of the goals of non-MAGI Medi-Cal is to extend coverage to vulnerable populations that would not normally qualify for Medi-Cal because their incomes are higher than 138% of the federal poverty level.
For a comprehensive list of the Medi-Cal covered groups with corresponding federal poverty levels, review the annual Medi-Cal mailer from the California Department of Health Care Services or contact Medi-Cal to see if you qualify.
When is Medi-Cal free?
MAGI Medi-Cal programs are generally free for individuals and families with incomes at or below 138% of the federal poverty level. The program is also free for many other populations covered under MAGI Medi-Cal and most beneficiaries covered under non-MAGI Medi-Cal.
What is Medicare, and who’s eligible?
Medicare, unlike Medi-Cal, is a national health care program that's funded and operated by the federal government.
Most people become eligible for Medicare by turning 65, thereby qualifying without having to meet income, health status or residency requirements, a profound difference from Medi-Cal and other state Medicaid programs.
More than 8 million individuals with disabilities or medical conditions such as end-stage renal disease (ESRD) also qualify for Medicare. And like seniors in the program, these beneficiaries do not have to meet income or residency requirements.
It is also important to note that Medicare provides coverage on an individual basis; coverage does not extend to spouses or other family members. For example, a couple can become eligible for Medicare at different times based on when each person’s 65th birthday is. That differs from Medi-Cal, where coverage can extend to family members within the household when the program’s income requirements are met.
Medicare is divided into four parts, and each part corresponds with at least one specific area of care.
- Part A helps to pay for hospitalizations and short-term skilled nursing facility care and hospice. Most beneficiaries do not pay premiums because they have paid a Social Security tax through employment for at least 10 years.
- Part B helps to pay for outpatient care such as doctor appointments. Beneficiaries are required to pay a Part B premium of $164.90 a month, and those who have higher incomes will pay more. Plus, beneficiaries are required to meet an annual deductible of $226 before Medicare Part B coverage begins.
- Part C, also known as Medicare Advantage, provides "all-in-one coverage" encompassing Medicare Parts A and B and usually prescription drug coverage. Costs will vary, and on average, a Medicare Advantage plan will cost $28 per month on top of what you pay for Medicare Part B.
- Part D provides prescription drug coverage for beneficiaries enrolled in Parts A and B but not enrolled in Medicare Advantage. The average cost is $49 per month.
Another add-on for those who are not enrolled in Medicare Advantage is a Medicare Supplement (Medigap) plan. Because Medicare Parts A and B only cover about 80% of your medical costs, a supplemental plan can fill in the coverage gaps so that you can spend less on your medical care.
Can you be enrolled in both Medi-Cal and Medicare?
There are currently 1.6 million beneficiaries in California who qualify for both Medicare and Medi-Cal.
Being dually eligible for both programs is a result of meeting the eligibility criteria for each. For example, you can qualify for Medicare by being older than 65 and qualify for Medi-Cal because of having a low income.
For those enrolled in both programs, Medi-Cal and Medicare work together in coordinating and providing care. With this type of arrangement, Medi-Cal wraps around Medicare coverage, helping to pay for Medicare premiums, copayments and deductibles.
Medi-Cal also provides additional benefits beyond what's usually included with Medicare Parts A and B, covering prescription drugs, dental, vision care, extended stays in skilled nursing facilities and long-term care in nursing homes.
Please note that those who have a low income (including those enrolled in Medi-Cal and Medicare) may qualify for free or low-cost prescription drug coverage through Medicare's Extra Help program.
In addition, there are many Medicare Advantage plans offered in California, including Special Needs Plans (SNPs) that are specifically designed for those who are dually eligible for Medicare and Medi-Cal.
Frequently asked questions
Is Medicare the same as Medi-Cal?
No. Medicare and Medi-Cal are two separate programs for health care coverage. Medicare is available nationally to cover seniors and people under the age of 65 with certain disabilities. Medi-Cal is California’s Medicaid program, covering low-income individuals and families in California.
What’s the maximum income to qualify for Medi-Cal?
In general, to qualify for Medi-Cal, a single adult can earn up to $1,677 a month ($20,120 per year) and a couple can earn up to $2,268 a month ($27,214 a year). For certain vulnerable populations such as children and pregnant women, Medi-Cal has higher income limits that make it easier to qualify.
How much is Medi-Cal per month?
Some of Medi-Cal’s programs are free, with no monthly cost for enrollees. Other Medi-Cal programs have a low monthly cost, depending on the program and the beneficiary's income. For example, coverage can cost $13 per month per child with a $39 maximum per family.
Can I have Medi-Cal and Medicare at the same time?
Yes. There are currently 1.6 million beneficiaries in California who are enrolled in both Medi-Cal and Medicare, and this is called dual enrollment.
What is the difference between Medi-Cal and Covered California?
Medi-Cal, California’s Medicaid program, provides free and low-cost health care coverage to those who have a low income. Covered California is the state's health insurance marketplace under the Affordable Care Act, where residents can shop for cheap health insurance plans and qualify for subsidies to get cheap health insurance.
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