Medi-Cal and Medicare Dual Eligibility Explained

Medi-Cal and Medicare are both government-run programs designed to provide individuals with health insurance. However, they serve different populations and have different eligibility requirements. While Medicare primarily covers individuals 65 and older and certain younger people with disabilities, Medi-Cal is California’s version of Medicaid, which provides health insurance to low-income individuals and families. However, some people are eligible for both Medi-Cal and Medicare, a condition called dual eligibility. Understanding how these plans work together can help you maximize your benefits and get comprehensive coverage.

What is Dual Eligibility?

Dual eligibility refers to the status of an individual who is eligible for both Medi-Cal and Medicare. This status is generally available to individuals who are 65 or older, or who have certain disabilities and meet the income and asset requirements required for Medi-Cal. When a person is dually insured, Medicare serves as the primary payer for medical care and Medi-Cal serves as the secondary payer, helping to cover costs that are not fully covered by Medicare. This combination of benefits can significantly reduce the medical costs you have to pay out of pocket, making it an important resource for those who qualify.

Dual Eligibility

To qualify for dual health insurance, a person must meet the eligibility requirements for both Medicare and Medi-Cal. Individuals who are 65 or older, or younger individuals who have received Social Security Disability Insurance (SSDI) for 24 months or more, are typically automatically eligible for Medicare. Medi-Cal eligibility, on the other hand, is based on income and family size, as well as certain asset limits. For many people, dual eligibility means meeting the income requirements for Medi-Cal while also being enrolled in Medicare.

In California, dually eligible individuals are often referred to as “Medi-Medi” beneficiaries. To qualify for Medi-Cal, a person generally must have a limited income and less than a certain amount of assets. Income and asset thresholds vary based on family size and other factors. Dual eligibility also applies to those who qualify for the Medicare Savings Program, which helps low-income Medicare beneficiaries pay premiums, deductibles, and co-pays.

How Medi-Cal and Medicare Work Together

When a person is dually insured, Medicare is the primary insurer and Medi-Cal acts as secondary coverage. This means that when a person receives health care, Medicare pays their share of the cost first. After Medicare pays, Medi-Cal pays the remaining costs, including co-pays, co-insurance, and deductibles, up to a limit set by Medi-Cal. In some cases, Medi-Cal also pays for services not covered by Medicare, such as dental care, vision care, and long-term care.

Medi-Cal can also help pay Medicare premiums, which can be a significant expense for beneficiaries. If you qualify for dual coverage, Medi-Cal can cover both your Medicare Part B premium (for outpatient care) and your Medicare Part A premium (if applicable). Medi-Cal can also help pay for other costs, such as prescription drugs, through the California Medi-Cal Prescription Drug Program.

Types of Insurance for People with Dual Coverage

People who qualify for dual coverage may have several health care options, depending on their health needs and preferences. One of the most common ways that people with dual coverage receive benefits is through a Medi-Cal managed care plan. This program is a type of health insurance that coordinates care and provides additional services to individuals enrolled in Medi-Cal and Medicare. Some counties in California offer managed care plans, which provide comprehensive health care options and make it easier for individuals to manage their Medicare and Medi-Cal benefits.

Another option for people with dual coverage is the Dual Eligible Special Needs Plan (D-SNP). This is a specialized Medicare Advantage plan designed specifically for people who are dually insured. These plans are offered by private insurance companies, but are approved by Medicare and Medi-Cal. D-SNPs coordinate care between Medicare and Medi-Cal, which provides a smoother experience for plan members. These plans offer

Additionally, full health insurance is usually not available. By reducing the co-pay, dual coverage can make health care more affordable for low-income individuals.

In addition to financial assistance, Medi-Cal can also provide services not covered by Medicare, such as long-term care, dental care, and mental health services. These additional benefits ensure that dual-payers have access to the comprehensive care they need.

How to Apply for Dual Eligibility

To qualify for dual coverage, an individual must first be enrolled in Medicare. For individuals who qualify for Medicare due to age or disability, enrollment is automatically processed through the Social Security Administration. Once you have health insurance, you must apply for Medi-Cal. You can complete the Medi-Cal application process online through the California Department of Health Care Services (DHCS) or at your local county office.

When applying for Medi-Cal, it is important to provide information about your income, assets, and family size to determine your eligibility. If you are eligible for Medi-Cal and meet the criteria, you are automatically considered dually insured. If you are already enrolled in Medicare but have not yet received Medi-Cal benefits, you can begin the dual eligibility process by applying at your local county office or online.

Benefits of Dual Eligibility

Dual eligibility has many benefits because it allows people to receive both Medicare and Medi-Cal benefits. This provides comprehensive coverage and reduces out-of-pocket costs. Through both programs, people can receive more comprehensive care, including services such as vision care, dental care, and long-term care that are normally only covered by Medicare. Medi-Cal also covers costs such as co-pays, deductibles, and premiums, making health care more affordable for low-income people.

For many people with chronic conditions, disabilities, or low incomes, dual coverage is essential to getting the care they need. Medicare’s broad coverage combined with Medi-Cal’s additional benefits ensure that dual-eligible individuals have access to a full range of health care services without incurring high medical bills.

In Conclusion

Dual eligibility for Medi-Cal and Medicare provides important health insurance coverage to individuals who qualify for both programs. For dual-eligible individuals, Medicare serves as their primary insurance and Medi-Cal serves as their secondary insurance, helping to pay for co-pays and services not covered by Medicare. Dual eligibility allows individuals to receive comprehensive care, including medical, dental, vision, and long-term care, while also receiving financial assistance to help reduce medical costs. Understanding the eligibility requirements and benefits of dual coverage can help you make the most of your available health care options.