Understanding the Differences Between Medicare and Medi-Cal

Medi-Cal and Medicare are similar in nature, but they usually cover individuals living under different circumstances.

Medicare and Medi-Cal both provide health coverage for American citizens, but they do so in different ways for different demographics. Medicare provides health coverage to individuals 65 and older or those with a severe disability regardless of income, whereas Medi-Cal (California’s state-run and funded Medicaid program) provides health coverage to those families with very low income, as well as pregnant women and the blind, among others.

Coverage is not mutually exclusive: individuals who are eligible for both programs may receive dual coverage.

What Is Medicare?

Medicare was signed into law by President Johnson in 1965 as a federal health insurance program designed to assist Americans over the age of 65 pay for their medical costs. Since then, Medicare has expanded significantly to cover more services and provide coverage to more people, including young people who are eligible for Social Security Disability benefits and those individuals suffering from end-stage renal disease.

Medicare is now divided into four distinct parts, with each providing different coverage types and packages:

  • Medicare Part A: Includes coverage for inpatient hospital and nursing facility stays, as well as hospice and some in-home healthcare. Premiums for Part A are mostly covered by payroll deductions while the individual was employed.
  • Medicare Part B: Includes coverage for doctor visits (including preventive services), medical supplies, and outpatient care. There does exist a monthly contribution, although this is usually expensed as a deduction in social security payments. (Taken together, Medicare Parts A and B are usually referred to as “Traditional Medicare” or “Original Medicare.”)
  • Medicare Part C: Also referred to 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: Part D was added as a Medicare option in 2003 and provides prescription drug coverage for those who have Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. This plan is available for purchase through private companies, and premiums are subsidized by the federal government.

What Is Medi-Cal?

Medi-Cal provides health coverage to low-income individuals and families for free or at significantly lower cost than those plans offered through Covered California. 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. 

Those individuals and families whose household income is equal to or more than 138% of the poverty line are eligible to receive health benefits through Medi-Cal. Additionally, individuals can also receive Medi-Cal if any of the following items apply to them:

  • Over the age of 65
  • Blind
  • Disabled
  • Under 21
  • Pregnant
  • Live in a nursing or intermediate care facility
  • Have received limited refugee status, depending on how long the individual has been in the United States
  • Have received breast and/or cervical cancer screening

Individuals enrolled in any of the following programs are also eligible to receive health benefits through Medi-Cal:

  • Cal Fresh
  • CalWorks (AFDC)
  • Refugee Assistance
  • Foster Care or Adoption Assistance Program

Eligible individuals can apply online at CoveredCA.com to determine if they qualify. They can also apply at their local county human services agency or by calling (800) 300-1516. Those individuals who qualify will receive a benefits identification card (BIC) to begin using in order to receive healthcare services. 

Medi-Cal participants will also receive a packet detailing 21 available health plans for them to choose from, although options will vary depending on the county in which you and your family reside. However, each county’s Medi-Cal plans provide high quality care at little or no cost, regardless of where you live. And with more than 400 hospitals and 13,000 doctors, dentists, pharmacists, and other participating medical providers, your clients should have no problem finding the best healthcare fit for their unique needs.