In California, some individuals qualify for both Medicare and Medi-Cal, a status known as dual eligibility or “Medi-Medi.” This provides a broader range of medical services with minimal or no out-of-pocket costs.
Medicare serves as the primary insurance, covering hospital stays, doctor visits, and outpatient care, while Medi-Cal acts as secondary coverage, paying for copayments, deductibles, and services not covered by Medicare.
This dual coverage is especially beneficial for low-income seniors and individuals with disabilities, as it reduces healthcare costs and ensures comprehensive medical care.
Medicare
Medicare is a federal health insurance program designed for:
- Individuals aged 65 and older
- Younger individuals with disabilities
- Those diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS)
Medicare is divided into four parts:
| Medicare Part | Coverage Details |
|---|---|
| Part A (Hospital Insurance) | Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most people qualify for premium-free Part A if they or their spouse have paid Medicare taxes. |
| Part B (Medical Insurance) | Covers doctor visits, outpatient care, preventive services, and durable medical equipment. Requires a monthly premium. |
| Part C (Medicare Advantage) | A private insurance alternative that combines Parts A, B, and often D, with extra benefits like vision, dental, and wellness programs. |
| Part D (Prescription Drug Coverage) | Helps cover prescription drug costs. Individuals with limited income may qualify for Low-Income Subsidy (LIS). |
Medi-Cal Complements Medicare
Medi-Cal, California’s Medicaid program, provides additional healthcare coverage for low-income individuals. It fills Medicare’s coverage gaps by covering:
- Copayments, deductibles, and out-of-pocket expenses
- Long-term care, including nursing home services
- Vision, dental, and hearing services
- Non-emergency medical transportation
- In-home supportive services (IHSS)
Medi-Cal also helps pay for Medicare Part B and Part D premiums through Medicare Savings Programs (MSPs).
Medicare Savings Programs
California offers four Medicare Savings Programs to help cover Medicare costs:
| Program Name | Coverage | Who Qualifies? |
|---|---|---|
| Qualified Medicare Beneficiary (QMB) | Pays Part A & Part B premiums, deductibles, and copayments | Individuals with very low income |
| Specified Low-Income Medicare Beneficiary (SLMB) | Pays Part B premiums only | Individuals with slightly higher income than QMB |
| Qualified Individual (QI-1) | Pays Part B premiums, but has limited funding | First-come, first-served basis |
| Qualified Disabled Working Individual (QDWI) | Pays Part A premiums for disabled individuals under 65 who have returned to work | Individuals who lost SSDI benefits |
Those enrolled in these programs automatically qualify for the Medicare Part D Low-Income Subsidy (LIS), which reduces prescription drug costs.
Prescription Drug Coverage
Medicare Part D covers prescription medications, but Medi-Cal does not pay for most prescriptions for Medicare recipients. Dual-eligible individuals must enroll in a Part D plan for medication coverage.
However, those with full Medi-Cal benefits are automatically eligible for Extra Help (Low-Income Subsidy), which significantly reduces:
- Prescription drug co-payments
- Part D premiums
- Deductibles
Medi-Cal
No. If you qualify for both Medicare and Medi-Cal, you must enroll in Medicare first. Medi-Cal acts as a secondary payer to cover costs Medicare doesn’t. If affordability is a concern, Medicare Savings Programs can help cover premiums and other expenses.
How to Apply
You must apply separately for Medicare and Medi-Cal:
- To apply for Medicare:
- Visit the Social Security Administration (SSA) website
- Apply in person at a local Social Security office
- Call 1-800-MEDICARE (1-800-633-4227)
- To apply for Medi-Cal:
- Visit the California Department of Health Care Services (DHCS) website
- Apply in person at a local Medi-Cal office
- Call the California Medicaid hotline for assistance
By knowing dual eligibility and how Medicare and Medi-Cal work together, you can ensure access to affordable, high-quality healthcare in California.
FAQs
What is dual eligibility?
Dual eligibility means qualifying for both Medicare and Medi-Cal, providing broader healthcare coverage at little to no cost.
What does Medi-Cal cover that Medicare doesn’t?
Medi-Cal covers copayments, deductibles, long-term care, vision, dental, and transportation services.
Can Medi-Cal pay for Medicare premiums?
Yes, Medicare Savings Programs help pay for Medicare Part A and Part B premiums for low-income beneficiaries.
Do dual-eligible individuals need Medicare Part D?
Yes, since Medi-Cal does not cover most prescriptions for Medicare recipients, Part D is required for medication coverage.
How can I apply for dual eligibility?
Apply for Medicare through SSA and apply for Medi-Cal through the California Department of Health Care Services.
