Medicare vs. Medi-Cal

What is the Difference Between Medi-Cal and Medicare?

The primary differences between Medicare and Medi-Cal are the eligibility requirements regarding residency, income and assets.

Medicare is a federal health insurance program that is available to eligible people throughout the United States. Medicare provides inpatient and outpatient healthcare coverage for people over 65, and for those with specific disabilities. U.S. citizens who meet the eligibility requirements for Medicare can get it, no matter what their income level. Your personal assets have no bearing on eligibility.

Medi-Cal is California’s Medicaid program. It is available to eligible people who live only in the state of California. Medi-Cal is funded equally by the federal government and the state. Medi-Cal is a public health insurance program which provides inpatient and outpatient healthcare to low-income individuals and their families. Medi-Cal also provides coverage to certain groups, such as pregnant people, and those who are disabled or blind. You may have some level of personal assets and still be eligible for Medi-Cal.

Medicare vs. Medi-Cal Eligibility and Coverage

Medicare eligibility

In order to be eligible for Medicare, you must be a U.S. citizen or a legal resident who has lived in the U.S. for five years or longer.

Most Medicare beneficiaries become eligible for Medicare once they turn 65 years old.

People with certain disabilities may also be eligible for Medicare, no matter how old they are. If you have been eligible for Social Security disability benefits for 24 months, you are eligible for Medicare.

People with end-stage renal disease (ESRD) and those with ALS (Lou Gehrig’s disease) are also eligible for Medicare. If you have ALS, you are eligible for Medicare starting the first month you receive disability benefits. If you have ESRD, your eligibility for Medicare will most likely start on the first day of the fourth month that you receive dialysis.

Medicare coverage

Medicare consists of multiple parts. Each part provides a different type or level of healthcare benefits.

Original Medicare

Original Medicare (Part A and Part B) provides combined healthcare coverage for inpatient and outpatient services. Most people who get Medicare are eligible for premium-free Part A. Part B requires a monthly premium.

Part A coverage includes:

• Inpatient hospital care
• Skilled nursing facility care
• Hospice
• Home health care
• Nursing home care

Part B coverage includes:

• Doctor’s appointments with your primary care physician and with specialists
• Preventive care, including most vaccines
• Disease screenings and tests
• Durable medical equipment
• Ambulance services
• Mental health services
• Tobacco use and substance abuse counselling and services

Medicare Advantage (Part C)

Part C is private healthcare insurance. It is an alternative way to get the coverage provided by Original Medicare. You must sign up for Original Medicare before you can sign up for a Part C plan.

Part C plans cover everything Original Medicare does, plus extras that Original Medicare does not cover. These may include:

• Prescription drugs
• Dental care
• Vision care
• Hearing care and hearing aids
• Gym memberships
• Over-the-counter drugs

Part D

Part D is Medicare’s prescription drug coverage. It is sold through private insurance companies. Part D is not mandatory, but most people find that having it is essential. You don’t need a separate Part D plan if you have a Part C plan that bundles drug coverage. If you’re on Original Medicare, you can add a Part D plan.

Medigap

Medigap is sold by private insurance companies. If you have Original Medicare, a Medigap plan may help provide financial coverage for your portion of your healthcare costs. Medigap plans cover the “gaps” in original Medicare and help beneficiaries pay for deductibles, coinsurance and copays. Medigap plans usually don’t offer additional benefits outside of what’s covered by Original Medicare, but there are some exceptions.

Medi-Cal eligibility

There are more than 90 eligibility categories for Medi-Cal. Each one has its own rules and requirements.

In general, your income level will be a determining factor for eligibility for most Medi-Cal programs. Medi-Cal is typically premium-free. Based on your income, you may be required to pay a small premium in some instances.

Some Medi-Cal categories are:

• Income-based Medi-Cal
• SSI-linked Medi-Cal
• Aged & Disabled Federal Poverty Level Medi-Cal
• Aged, Blind & Disabled Medically-Needy Medi-Cal

If you are a California state resident and U.S. citizen, you will be eligible for Medi-Cal if your combined household income is at or less than 138% of the Federal Poverty Level.

Asset limits for singles and for couples also apply. In many instances you can own a home and a vehicle and still be eligible for Medi-Cal.

You may also be eligible for Medi-Cal if you meet one or more of these criteria:

• You qualify for Supplemental Security Income
• Blindness
• Under age 21
• Pregnancy
• Disability
• Live in a skilled nursing facility
• Live in an intermediate care home
• Have refugee status for a limited time
• You’re in foster care

Medi-Cal maximum income

The maximum income for Medi-Cal is based upon your entire household’s earnings. When you apply, the number of people you live with will be taken into account.

If you are applying for Income-Based Medi-Cal and are under 65, your family’s income must be at or below 138% of the Federal Poverty Level.

If you are qualified for Medi-Cal due to a disability, or if you are also enrolled in Medicare, you may be eligible even if your income is higher.

Medi-Cal coverage

Medi-Cal covers medically necessary healthcare services. These include:

• Doctor’s appointments
• Diagnostic tests, such as X-Rays
• Laboratory tests
• In-patient hospital care
• Nursing home care
• Durable medical equipment including prosthetics
• Hearing aids
• Ambulance services
• Hospice care
• Dental services
• Prescription drugs