Dual Eligibility for Medicaid and Medicare

Medicare and Medi-Cal are both government funded health insurance programs, but they differ in function, recipients, and funding.

Medicare and Medi-Cal are two government funded health insurance programs available to Californians. While the programs do have some similarities, they are quite different from each other. Their core functions, beneficiaries, eligibility, and funding are all different. Even though there are significant differences between the two programs, some Californians are eligible for both programs and can be covered by both simultaneously.

What Is Medicare?

Medicare is a federal health insurance program for Americans aged 65 years and older to help pay for medical care. Since its inception in 1965, Medicare has expanded to provide more coverage to more people, including young people with disabilities and certain diseases. Medicare is offered regardless of past, current, or future income.

Medicare coverage varies. It can cover basic services and cost little-to-no money out-of-pocket and can be comprehensive with a higher premium. This federal government healthcare program is available in four parts, enabling individuals to receive the coverage they need.

  • Medicare Part A: Medicare Part A includes coverage for inpatient hospital and nursing facility stays and hospice and some in-home healthcare services. Premiums are mostly covered by taxes paid from payroll deductions while the individual was working.
  • Medicare Part B: As a supplement to Part A, Medicare Part B includes coverage for doctor visits, medical supplies, and outpatient care. It is paid for with a monthly contribution and is usually expensed as a deduction in social security payments. When used together, Medicare Parts A and B are referred to as “Traditional Medicare” or “Original Medicare.”
  • Medicare Part C: Also known as a “Medicare Advantage Plan,” Part C is an alternative insurance plan offered by private insurers that provides Traditional Medicare and prescription drug coverage under a single policy.
  • Medicare Part D: Provides prescription drug coverage for those who have Original Medicare. This plan is through private insurance companies with federally subsidized premiums.

Medicare is a valuable program for those who qualify and is often the only way older individuals can get health insurance. For those under the age of 65 who need insurance, there is another publicly funded health insurance program: Medi-Cal.

What Is Medi-Cal?

Medi-Cal is a California-state run Medicaid program funded by the federal and state governments. It provides medical care coverage to low-income individuals and families at no charge or a significantly lower premium than Covered California plans. Families and individuals with a household income equal to or more than 138% of the poverty line can receive health benefits through Medi-Cal. 

Additionally, certain societal groups or individuals with qualifying health statuses can make individuals eligible for Medi-Cal, including:

  • Seniors (individuals over 65 years of age)
  • Families with children
  • A qualifying disability
  • Foster care
  • Pregnancy
  • Living in a nursing or intermediate care facility
  • Certain diseases such as tuberculosis, breast cancer, and HIV/AIDS

Like all plans offered through the Health Exchange, Medi-Cal plans are required to offer certain “essential health benefits,” such as emergency services, hospitalization, mental health services, and addiction treatment.

Dual Eligibility

In certain situations, Californians can be eligible for both Medicare and Medi-Cal. Although it is possible to enroll for both at once, most individuals or families are enrolled in one program and then become eligible to enroll in the other.

An individual over the age of 65 on Medicare could eventually qualify for Medi-Cal depending on how long they live or the cost of their medical care throughout the years, or if there is a drastic change in their income. Alternatively, an individual with Medi-Cal benefits can qualify for Medicare by aging into the program or receiving a qualifying diagnosis like end-stage renal disease.

Those who are eligible for both Medi-Cal and Medicare are more likely to have at least one disabling condition than those who utilize only Medicare or only Medi-Cal, and the cumulative medical needs of dual enrollees require a wide range social and health services. The disabling conditions can include limitations performing daily tasks like working, bathing, and dressing. Additionally, dual beneficiaries are statistically more likely to struggle with mental or emotional disorders. They also have a higher risk for chronic conditions like diabetes, Alzheimer’s, heart or pulmonary diseases, and stroke. Thankfully, most individuals enrolled in both programs can get the services they need for these debilitating conditions.