How Does Medicare and Medi-Cal Work Together?

Medicare and Medi-Cal are distinct government healthcare programs. Medicare is a federal health insurance program primarily for people aged 65 or older, and certain younger individuals with disabilities or specific medical conditions. Medi-Cal, on the other hand, is California’s Medicaid program, providing comprehensive health coverage to low-income individuals and families within the state. While they operate independently, these programs frequently interact, providing coverage for those who qualify for both.

Understanding Medicare and Medi-Cal Basics

Medicare offers different parts. Medicare Part A, known as hospital insurance, helps cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health services. Medicare Part B, or medical insurance, assists with medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, and some preventive services. These two parts together form what is often referred to as Original Medicare.

Beyond Original Medicare, individuals can choose other options. Medicare Part C, also known as Medicare Advantage, is offered by private companies approved by Medicare and includes all the benefits of Parts A and B, often bundling in Part D prescription drug coverage and additional benefits like vision, hearing, or dental services. Medicare Part D provides prescription drug coverage, also administered by private insurance companies, helping to cover the costs of prescription medications.

Medi-Cal, as California’s Medicaid program, provides extensive health coverage to eligible low-income residents. This program covers a broad range of services, including doctor visits, hospital care, prescription drugs, mental health services, and preventive care. Most individuals with Medi-Cal do not incur co-pays or out-of-pocket costs for covered services.

Qualifying for Both Programs

Individuals can qualify for both Medicare and Medi-Cal, a status known as “dual eligibility.” This requires meeting Medicare’s age or disability criteria while also adhering to Medi-Cal’s income and asset limits. Medicare eligibility begins at age 65, or for younger individuals with certain disabilities, end-stage renal disease, or amyotrophic lateral sclerosis (ALS). For example, those receiving Social Security Disability benefits become eligible for Medicare after a 24-month waiting period.

Medi-Cal eligibility for seniors and persons with disabilities has specific income thresholds. For instance, as of April 1, 2025, the countable monthly income for an individual in the Aged & Disabled Federal Poverty Level (A&D FPL) program must be below $1,801, and for a couple, below $2,433. While asset limits have been eliminated for most Medi-Cal programs as of January 1, 2024, some specific programs, like Supplemental Security Income (SSI), still maintain an asset limit of $2,000 for an individual and $3,000 for a couple.

Several Medicare Savings Programs (MSPs) exist to help dual-eligible individuals with Medicare costs, with eligibility tied to income levels relative to the federal poverty level. These programs include Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualifying Individuals (QI). The QMB program, for example, helps pay for Medicare Part A and Part B premiums, deductibles, and coinsurance for those with income at or below 100% of the federal poverty guidelines. SLMB and QI programs offer assistance with Part B premiums for those with slightly higher incomes.

How Medicare and Medi-Cal Coordinate Coverage

When an individual is eligible for both Medicare and Medi-Cal, the two programs coordinate to provide comprehensive health coverage. Medicare acts as the primary payer for services it covers, meaning it pays for eligible medical expenses first. Medi-Cal then functions as the secondary payer, stepping in to cover costs that Medicare does not, such as deductibles, copayments, and coinsurance for Medicare-covered services. This coordination results in little to no out-of-pocket costs for the dual-eligible individual.

Medi-Cal also plays a role in covering Medicare premiums. For example, for individuals enrolled in the Qualified Medicare Beneficiary (QMB) program, Medi-Cal automatically pays their Medicare Part A and Part B premiums. Even for those with a “share of cost” for Medi-Cal, meaning their income is above the Medi-Cal limit but they still qualify with an out-of-pocket spending requirement, Medi-Cal can help with Medicare Part B premiums if they meet certain criteria.

Regarding prescription drugs, Medicare Part D is the primary payer for medications. However, Medi-Cal can provide additional assistance, potentially covering drugs not included on a Medicare Part D plan’s formulary or offering a low-income subsidy (LIS), also known as “Extra Help,” to help with Part D premiums, deductibles, and co-payments. Individuals with both full Medi-Cal benefits and Medicare automatically receive this low-income subsidy for Part D.

Beyond Medicare-covered services, Medi-Cal may cover a range of additional benefits that Medicare does not. These can include long-term care services in a nursing facility, certain non-emergency medical transportation, and comprehensive dental and vision care.

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan designed for individuals who have both Medicare and Medi-Cal. These plans integrate and coordinate benefits from both programs, providing a more streamlined healthcare experience. D-SNPs include extra benefits beyond Original Medicare, such as dental, vision, and hearing care, and can simplify the process of navigating multiple health coverage programs.

Navigating Enrollment and Assistance

Applying for Medicare involves contacting the Social Security Administration (SSA). Individuals can apply for Medicare Part A and Part B online through the Social Security website, by phone, or in person at a local Social Security office. The application process for Medicare Part A and Part B can take between 10 to 30 minutes online, and coverage begins within one to two months, depending on the enrollment period.

For Medi-Cal, applications can be submitted through various channels, including online via Covered California or BenefitsCal, by mail, or in person at a local county social services office. When applying for Medi-Cal, individuals need to provide documents verifying their identity, Social Security number, income, and California residency. For those seeking dual eligibility, applying for Medi-Cal is the pathway to automatically qualify for Medicare Savings Programs if income and asset criteria are met.

Several resources are available to help individuals navigate the process of Medicare and Medi-Cal enrollment and benefits. California’s Health Insurance Counseling and Advocacy Program (HICAP) offers free, unbiased one-on-one counseling and assistance on Medicare-related questions, including Medicare Savings Programs and coordination with Medi-Cal. HICAP counselors do not sell or endorse any insurance products.

Local county social services offices are another resource, providing direct assistance with Medi-Cal applications and offering information on eligibility and benefits. These offices can help individuals understand the requirements and documentation needed.