Understanding Medicare & Medi-Cal

Medicare Health Insurance Card
Medi-Cal Benefits Card
Some people qualify for both Medicare and Medi-Cal and are called “dual-eligible” or Medi-Medi beneficiaries. It is important for you to know the differences between Medicare and Medi-Cal, and how Medicare works with Medi-Cal, and who is responsible for paying your medical bills.
It is also important for you to know and understand your options for receiving your Medicare coverage, and, how Medi-Cal works with Medicare for each of the options.
When you have Medicare Parts A and B, Medicare is your primary insurance and pays for most of your medical care. Medi-Cal is your secondary insurance. It pays for costs not covered by Medicare and provides additional benefits not covered by Medicare.

What is Medicare?

Medicare is health insurance for:

  • People 65 or older
  • People under 65 with certain disabilities
  • People of any age with End-Stage Renal Disease (ESRD) – permanent kidney failure requiring dialysis or a kidney transplant
  • People of any age with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease

You have Medicare if you have this card:

medicare-health-insurance-card

Medicare consists of 4 parts:

  • Part A (Hospital Insurance) – covers inpatient hospitalization; hospice; home health
  • Part B (Medical Insurance) – covers outpatient care, services from doctors and other medical providers, durable medical equipment; many preventive services
  • Part C (Medicare Advantage) – plans that cover all benefits and services under Parts A and B and usually covers prescription drug benefits. Plans may also include extra benefits and services not covered by Medicare such as basic vision and hearing.
  • Part D (Prescription Drug Coverage) – covers prescription drug costs

Medicare beneficiaries can choose how to receive their Medicare benefits and services:

  • Keeping Original Medicare (traditional Medicare) plus a stand-alone Prescription Drug Plan, or,
  • Enrolling in a Medicare Advantage Plan (HMOs or PPOs). Most of these plans also include prescription drug coverage.

What is Medi-Cal?

Medicaid, called Medi-Cal in California, is a joint federal and state program that helps pay medical costs for people with limited income. Some people qualify for both Medicare and Medi-Cal.

You have Medi-Cal if you have either of these cards:

Medi-Cal Benefits Card
older-medi-cal-card

What does Medi-Cal cover?

  • If you have Medicare and full Medi-Cal coverage, most of your health care costs are covered.
  • People with Medi-Cal may get coverage for services that Medicare may not or may partially cover, like basic vision and hearing, dental, non-emergency transportation, incontinence supplies, personal care, and home-and community-based services.

How do I qualify?

Your income must meet the state eligibility requirements.

Where do I enroll?

  • Contact Social Services Agency of Orange County: (800) 281-9799
  • For individuals receiving SSI, contact Social Security Office: (800) 772-1213

Who administers Medi-Cal in Orange County?

  • CalOptima administers the Medi-Cal Program: (714) 246-8500

  • Kaiser administers the Medi-Cal Program for Kaiser members (800) 464-4000

What is Medi-Cal with Share of Cost?

  • People with Medi-Cal and a Share of Cost refers to individuals with income too high to meet the Medi-Cal income limit requirement.

  • Share of cost (SOC) works similar to a monthly insurance deductible.

  • You must meet your monthly SOC before Medi-Cal starts to pay.

  • You will get billed for medical related services until you meet your share of cost.

  • You DO NOT have full Medi-Cal benefits until you meet your share of cost.

How can I eliminate or meet my share of cost?

  • Purchase private health insurance that charges a premium, like prescription drug, dental, or vision plans
  • Use the amounts you pay for Medicare co-payments, deductibles, prescription drug costs, and other health related services, such as dental or vision

What Coverage Options are available for Medi-Medis?

Option 1: Original Medicare

  • Medicare is primary and Medi-Cal is secondary. In Original Medicare, also known as fee-for-service, it is important to present providers with both Medicare and Medi-Cal cards. With Original Medicare you can choose any medical provider that accepts Medicare and Medi-Cal, no referral to a specialist is needed.

  • In addition to the Medicare and Medi-Cal card, beneficiaries also have a CalOptima Member Identification card and a Part D Prescription Drug Plan card.
  • Medi-Medi beneficiaries that do not enroll in a Part D Plan or a Medicare Advantage Plan will automatically be enrolled in a Part D benchmark plan. Medi-Medi beneficiaries are automatically eligible for Extra Help, the program that helps pay for prescription drug plan co-payments.
Medicare Health Insurance Card

Medicare

Medicare Prescription Drug Plan

Prescription Drug Plan

Medi-Cal Benefits Card

State Medi-Cal

Medi-Cal Benefits Card

Medi-Cal Managed Care

Option 2: Medicare Advantage Plans (MA) (Medicare Part C)

  • Medicare Advantage Plans are a type of Medicare health plan offered by private companies that contract with Medicare to provide Part A and Part B benefits. Most Medicare Advantage Plans also offer prescription drug coverage.

  • MA plans may also offer extra benefits such as vision, dental, hearing, fitness, or non-emergency transportation.

  • In Orange County, Medicare Advantage plan are either an HMO or PPO. Plan members are assigned a medical group (network of providers) and referrals are required prior to seeing a specialist. MA plans pay first, and Medi-Cal pays any remaining cost sharing amounts. Beneficiaries need only present their MA Plan card when obtaining medical services.

  • There are also specialized Medicare Advantage Plans, called Special Needs Plans (SNP). These plans limit membership to people with certain conditions, limited income, or those requiring nursing home level of care. SNPs tailor their benefits, provider choices, and drug formularies to best meet the needs of the groups they serve in these three areas:

    1. People with certain chronic conditions (C-SNP)
    2. People who live in certain institutions (like nursing homes) or who live in the community but require nursing care at home (I-SNP)
    3. People who are eligible for both Medicare and Medi-Cal (D-SNP)
Medicare Advantage Plan

Primary Medi-Care Advantage Plan

Medi-Cal Benefits Card

Medi-Cal Managed Care

Medi-Cal Benefits Card

State Medi-Cal

Kaiser HMO

Medi-Cal Managed Care

Are there plans just for people with Medicare and Medi-Cal?

Yes. Dual-Eligible Special Needs Plans (D-SNPs) are for people covered by both Medicare and Medi-Cal. These individuals are also referred to as dual-eligible or Medi-Medi. D-SNPs provide Medicare and Medi-Cal benefits, including specialized care and wrap-around services for their plan members.
D-SNPs with exclusively aligned Medi-Cal plans are called Medicare Medi-Cal (Medi-Medi) Plans, which combine Medicare and Medi-Cal benefits, including prescription drug coverage, into one, integrated plan. These plans coordinate your care, benefits, and services across Medicare and Medi-Cal.
In Orange County, three D-SNPs are Medicare Medi-Cal plans. CalOptima Health offers OneCare Complete and OneCare Flex Plus, and Kaiser Permanente offers Dual Complete South P1.
onecare-complete-sample-card

Your Rights & Protections

  • Medi/Medi beneficiaries should not be billed for Hospital & Medical Services, it may be improper billing

  • Make sure to check that your prescription drugs are covered under the plan

  • There is a Special Enrollment Period for people receiving Extra Help or designated as Medi/Medi.

We Can Help

Call HICAP for additional information or schedule a counseling appointment

HICAP Statewide (800) 434-0222
Orange County (714) 560-0424

Health Insurance Counseling & Advocacy Program

Services also available in Spanish, Vietnamese, Korean, Chinese and Farsi
HICAP does not sell or endorse any insurance products
state-health-insurance-assistance-program-logo

This project is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $666,178 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.

This product is a result of a project funded by a contract with the California Department of Aging and administered by the Orange County Office on Aging.