Medi-Cal for People with Medicare
https://cahealthadvocates.org/low-income-help/medi-cal-for-people-with-medicare/
Medi-Cal, the Medicaid program in California, provides health coverage to people with low-income and asset levels who meet certain eligibility requirements. While there are several ways to qualify for Medi-Cal, this section focuses only on Medi-Cal beneficiaries who also qualify for Medicare — individuals who are over a certain age and/or disabled. People who qualify for both Medicare and full Medi-Cal are known as “dual eligibles” or “Medi-Medis.”
Medi-Cal pays for “medically necessary” health care such as:
Medi-Cal will only cover these costs and services if you use providers that accept Medi-Cal. If you have both Medicare and Medi-Cal, Medicare is the primary payer (meaning Medicare will pay first for Medicare-covered benefits) and Medi-Cal is the secondary payer. If you qualify for full Medi-Cal (Medi-Cal without a share of cost (SOC)), Medi-Cal will also cover your Medicare Part A and B deductibles and copayments, and pay your monthly Medicare Part B premium. Learn more.
If you have both Medicare and Medi-Cal, how you receive your benefits depends on what coverage option you choose for your Medicare.
For Medicare benefits, you may choose fee-for-service Original Medicare in all counties, or a Medicare Advantage (MA) plan, if available in your county. If you choose an MA plan, the MA plan that works best for people with both Medicare and Medi-Cal is the Special Needs Plan (SNP) for dual eligibles or D-SNP. If you’re enrolled in a D-SNP, you do not have copays, coinsurance or premiums associated with other types of MA plans.
Another type of MA plan designed for people with both Medicare and Medi-Cal is a “look-alike” or “mirror” D-SNP. While others on Medicare can join this type of MA plan, the premiums, copayments, and co-insurance are waived for those on Medicare and Medi-Cal. D-SNP “look alikes” are being phased out under certain conditions. For more information, see the Center for Medicare and Medicaid Services’ (CMS) memo, Dual Eligible Special Needs Plan “Look-Alike” Transitions for Contract Year 2023. For more information on MA plans, see our Medicare Advantage section.
For Medi-Cal benefits, as of January 1, 2023, you must join a Medi-Cal managed care plan if you do not have a share of cost. This change is due to the Department of Health Care Services’ (DHCS) multi-year project, CalAIM (California Advancing and Innovating Medi-Cal).
Some exceptions include people with Medicare and Medi-Cal who have a share of cost living in the community (versus a Skilled Nursing Facility), those enrolled in a SCAN health plan, Program of All Inclusive Care for the Elderly (PACE) enrollees, residents of California veteran homes, and Native Americans who chose fee-
for-service Medi-Cal.
If you fall into one of these exceptions, you can choose fee-for-service Medicare and Medi-Cal. Make sure your doctor or hospital accepts Medi-Cal as well as Medicare. Present both your Medicare card and your Medi-Cal Benefits Identification Card (BIC) to your doctors and other providers when receiving services, so that they can bill Medicare and Medi-Cal directly.
If you enroll in a Medicare Advantage plan, you must see doctors and other providers in the plan’s network, except for emergency and urgent care. Make sure any doctors you want to continue seeing are in that plan’s network. See DHCS fact sheets, Medicare Medi-Cal Plans: Information for Providers and The Facts on Balance Billing.
Note If you live in one of the following seven counties (Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo or Santa Clara) and have been in a Cal MediConnect plan, you should have been automatically enrolled into an Exclusively Aligned Enrollment Dual Special Needs Plan (EAE D-SNP) operated by the same parent company as the Cal MediConnect plan. These plans are also referred to as Medicare Medi-Cal Plans or MediMedi Plans (MMPs). Cal MediConnect plans ended as of December 31, 2022. See our Cal MediConnect section.
If you are receiving both Medicare and Medi-Cal benefits, the Medicare Part D drug benefit will provide your prescription-drug coverage instead of Medi-Cal. You must be enrolled in a Medicare Part D drug plan or a Medicare Advantage prescription drug plan to get these benefits. Medi-Cal, however, will pay for certain categories of drugs not covered by Part D, including:
Medi-Cal will pay for these drugs through your respective Medi-Cal managed care plan.
If you are exempt from the mandatory enrollment in a Medi-Cal managed care plan and opt for fee-for-service Medi-Cal, you will continue to receive your Medi-Cal covered drugs through the MediCal Rx program, which started January 1, 2022. Call the Medi-Cal Rx Call Center Line at 1-800-977-2273 or visit medi-calrx.dhcs.ca.gov/ for more information.
With Medicare Part D drug coverage, you must make copayments of no more than $1.45 for generic drugs and $10.35 brand name drugs in 2023. The Low-Income Subsidy (LIS) program, also known as the “Extra Help” program, will pay for part or all Medicare Part D drug-benefit plan premiums, depending on the plan in which you are enrolled. Learn more about the Extra Help program and the Medicare Part D drug benefit.
Cal MediConnect was a demonstration program with the goal of integrating care for people with both Medicare and Medi-Cal. The demonstration happened in 7 selected counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara, and ended as of December 31, 2022.
All Cal MediConnect members were automatically enrolled into an Exclusively Aligned Enrollment Dual Special Needs Plan (EAE D-SNP) operated by the same parent company as the CalMediConnect plan in their county, also referred to as a Medicare Medi-Cal Plan (MMP). The transition was effective January 1, 2023. These enrollees transitioned to an MMP should have received notices regarding this transition in fall 2022.
These transitioned beneficiaries continue to have access to a complete provider network through their Medicare Medi-Cal plan (MMP). The provider network should include the providers they had been seeing in their Cal MediConnect plan. If not, their plan will help them find a new doctor they like. For more information, see the Department of Health Care Services’ webpage and fact sheet: Cal MediConnect Transition – Information for Beneficiaries webpage and Joining a Medicare
Medi-Cal Plan (Medi-Medi Plan).
To find out if you qualify for one of Medi-Cal’s programs, look at your countable asset levels. As of July 1, 2022, you may have up to $130,000 in assets as an individual, up to $195,000 in assets as a couple, and an additional $65,000 for each family member. These asset levels are for all the programs listed below except Supplemental Security Income (SSI). For SSI, the asset levels are $2,000 for an individual and $3,000 for a couple.
Some of your personal assets are not considered when determining whether you qualify for Medi-Cal coverage. For example, assets that do not count are:
If you meet the asset requirements, your income determines the Medi-Cal program for which you qualify.
| Asset limits are the same for all programs, except SSI: Single: $130,000; Couple: $195,000 SSI asset limits are: Single: $2,000; Couple: $3,000 | |
| Program / Requirements | Your Monthly Income |
| Supplemental Security Income (SSI) 65 or older, blind or disabled | Single: up to $1,040.21/mo. Couple: up to $1,765.64/mo. Note: Higher income levels apply for individuals who are blind. |
| Aged & Disabled Federal Poverty Level (A&D FPL) Program 65 or older, blind or disabled | Single: up to $1,696/mo. Couple: up to $2,287/mo. (Note: these amounts were calculated from the 2023 Federal Poverty Level figures. Official A&D FPL Program income amounts for 2023 will be released in April). |
| Medi-Cal with a Share of Cost (SOC) 65 or older, blind or disabled | Single: over $1,584/mo. Couple: over $2,126/mo. |
| 250% California Working Disabled (CWD) Have workMeet Social Security’s definition of disabilityPay small monthly premium | Single: up to $2,853/mo. Couple: up to $3,835/mo. Note: Income excludes disability benefits |
If you qualify for Supplemental Security Income (SSI), you automatically qualify for full Medi-Cal coverage. To qualify for SSI, you must be age 65 or older, blind or disabled. Your countable monthly income may not exceed $1,040.21 for an individual or $1,765.64 for a couple (higher income levels apply for individuals who are blind). And your assets may not exceed $2,000 for an individual and $3,000 for a couple.
If you are aged (65+) or disabled and are not eligible for the SSI program, you may be able to get Medi-Cal through the Aged & Disabled Federal Poverty Level (A&D FPL) program. To qualify, you must:
This Medi-Cal program uses SSI countable income rules as well as a few extra rules you should know. For more information, visit the Medi-Cal section of the Disability Benefits 101 website.
If your monthly income is higher than the limits to qualify for SSI or the A&D FPL program (see above), but you meet the asset-level requirements, you may still be eligible for Medi-Cal with a share of cost (SOC). An SOC functions like a deductible. You must pay this amount in any month you incur medical costs. After your SOC is paid, Medi-Cal will pay the remaining amount of your medical bills for that month.
Note: A SOC is not a monthly premium. It is more like a deductible. It is the amount of medical expenses you are responsible to pay for before you can get full Medi-Cal coverage for the remainder of the month. If you have no medical expenses, you pay nothing.
Your SOC is determined according to your monthly income, using the following formula: Medi-Cal subtracts $600 (for an individual) or $934 (for a couple) from your monthly income, and any other health-insurance premiums you may be paying.
For example, if you have an individual monthly income of $1,600, Medi-Cal subtracts $600 for a SOC of $1,000. This means you must pay at least $1,000 in covered medical expenses and/or health care premiums in a given month before Medi-Cal covers any of your health care costs for that month. For people with a high SOC, Medi-Cal is mostly a form of catastrophic coverage, meaning Medi-Cal will most likely only help them for emergencies or high-cost medical conditions.
Note: If you have Medi-Cal with a SOC, Medi-Cal will not pay your Medicare Part B monthly premium. This means your Part B premium will be deducted from your Social Security check each month. One exception applies if you are in a Medicare Savings Program (MSP) that pays for your Part B premium (QMB, SLMB or QI). If you are in one of these MSPs, you will not be affected.
If you meet your SOC with medical costs in any given month, Medi-Cal will retroactively pay your Part B premiums for the month(s) in which the SOC is met. Medi-Cal will send the payment to the Social Security Administration (SSA), which will refund you the amount of the premium. Any Part B premium refund received from the SSA will be counted as a resource, not income, in the month you receive it.
The 250% California Working Disabled (CWD) program helps Californians who are working, disabled and have income too high to qualify for free Medi-Cal. Californians who qualify may be able to receive Medi-Cal by paying a small monthly premium based on their income. Premiums range from $20 to $250 per month for an individual or from $30 to $375 for a couple.
To qualify, you must:
Also learn about how AB 1269 made the California Working Disabled program event better. This bill was signed into law in 2009 and became effective August 2011.
All these CWD rules are explained in more detail in the Medi-Cal section of the Disability Benefits 101 website.
When you apply and qualify for Supplemental Security Income (SSI) at your local Social Security Administration office, you are automatically enrolled in Medi-Cal and will be sent a Benefits Identification Card (BIC). If you do not qualify for SSI, you may still qualify for Medi-Cal with or without a share of cost (SOC). Contact your Medi-Cal county office for more information.
If you or your spouse anticipates placement in a nursing home, contact your Department of Public Social Services (DPSS) county office to learn about the Medi-Cal rules for long-term care. These rules are very different than the rules that apply if you are not in a nursing home. Learn more about qualifying for Medi-Cal long-term care coverage.
Note: If you are hospitalized and think you may need to go into a nursing home, you may also ask the hospital’s Medi-Cal specialist for assistance.
Apply for Medi-Cal as soon as possible if you think you may not be able to afford your medical expenses or nursing-home placement. Processing your application can take several weeks because Medi-Cal must first determine eligibility by verifying your income and personal assets before coverage can be approved. You may request Medi-Cal to pay retroactively for the three months prior to the month in which you apply.
