Both Medicare and Medi-Cal provide health care coverage for residents of California. However, the two programs have key differences that are important to understand so that you know which one is right for you.
Key Difference Between Medicare and Medi-Cal
The key difference between Medicare and Medi-Cal is who the programs are intended for. Medicare is a federal health insurance program for people 65 and older, or those with disabilities. Medi-Cal is the state of California’s version of Medicaid, intended for those with low income regardless of age.
Understanding Medicare
Medicare is a federal program that you have likely been paying into through payroll taxes throughout your life. When you turn 65, you automatically qualify for Medicare, but you may also qualify if you meet certain disability criteria, regardless of your age. There are no income or asset limits to be eligible for Medicare.
Understanding Medi-Cal
Medi-Cal is the state of California’s version of Medicaid and is overseen by the Department of Health Care Services (DHCS). It is for low-income residents of California and their families and makes no-to low-cost health care coverage accessible to many people who cannot afford private health insurance.
Medicare Basics
It’s important to know the basics about who qualifies for Medicare, and what Medicare covers.
Who Qualifies for Medicare?
To qualify for Medicare, you must be 65 or older and a U.S. citizen or legal resident that has lived in the United States for five years or longer. You can also qualify if you’re younger than 65 and have been receiving Social Security Disability income for at least 24 months. If you have end-stage renal disease (ESRD) or ALS (Lou Gehrig’s disease), you can qualify regardless of your age.
What Does Medicare Cover?
Medicare has four coverage parts.
- Medicare Part A covers hospital stays, skilled nursing facility care, some home health services, and hospice. It usually has no premium payment required.
- Medicare Part B covers doctor visits, preventive care, outpatient services, and medical equipment such as wheelchairs. Part B does have a required premium.
- Medicare Part C, also known as Medicare Advantage, combines Parts B and C and comes with extra benefits, but also comes with a premium.
- Medicare Part D covers prescription medications and has a premium.
Medi-Cal Basics
Medi-Cal eligibility requirements and covered services are different than those of Medicare.
Who Qualifies for Medi-Cal?
To be eligible for Medi-Cal, you must live in California and meet certain eligibility requirements. These include:
- Income Limits
- For adults, the limit is 138% of the federal poverty levels (FPL), which is $21,597 per year for one person, $44,367 per year for a family of four.
- For children 19 and under, the limit is 266% of FPL, which is $41,629/year for one, $85,519/year for a family of four.
- For pregnant women, the limit is 322% FPL, or up to 213% FPL depending on certain rules.
- Assets: In 2026, asset limits are $130,000 for one person, $195,000 for a couple. In some cases, there may be no asset limits.
- Immigration Status: You must be a citizen or meet certain immigration requirements. However, some benefits are available regardless of status, particularly for children and pregnant women.
What Does Medi-Cal Cover?
Medi-Cal offers comprehensive coverage for a variety of services, including
- Medical services, such as routine doctor visits, preventive care, inpatient and outpatient hospital services, emergency services, and prescriptions
- Dental care (Denti-Cal) for adults and children, including services like exams, cleanings, X-rays, fillings, root canals, dentures, and some oral surgeries.
- Vision care including routine eye exams, coverage for eyeglasses or contact lenses, and treatment for eye diseases.
- Mental health and substance use services including outpatient therapy and counseling, psychiatric services, inpatient mental health care, and substance use disorder treatment programs.
- Pregnancy and family planning including prenatal care, labor and delivery, and postpartum care for up to 12 months. Family planning services, including birth control and reproductive health care, are also included.
- Children’s services (EPSDT) including regular developmental screenings, vision and hearing services, behavioral health care, and therapies such as speech, occupational, and physical therapy.
- Transportation services including non-emergency medical transportation for members who need help getting to medical appointments.
- Long-term and in-home care such as nursing home care and home health services.
- Additional services including medical equipment, hospice and palliative care, home health visits, and interpreter services.
Dual Eligibility
Many people quality for both Medicare and Medi-Cal, which provides them with broader coverage and minimizes their out-of-pocket costs. To be eligible for both requires meeting the eligibility requirements for both programs. For example, you may turn 65 but still have a low income that qualifies you for Medi-Cal.
When you have the coverage of both programs, Medicare is considered your primary coverage, while Medi-Cal is secondary.
Dual coverage has several benefits.
- Medi-Cal pays for your Medicare premium and other out-of-pocket costs.
- You get coverage for services that Medicare doesn’t cover, such as long-term care.
- You can go to both Medicare and Medi-Cal providers.
Which Is Right for You?
Which one is right for you is simply based on eligibility. If you are over 65 or disabled, Medicare is available. If you are under 65 and have a low income, you may qualify for Medi-Cal. If you meet the eligibility requirements for both, you can have dual coverage.
In Closing
Medicare and Medi-Cal are both valuable programs, providing health care coverage for many people. At Health Service Alliance, we accept both plans. If you are not yet covered by either but think you may be eligible, we can provide you with guidance and resources to get the healthcare coverage you need, but your health is our top priority. We are dedicated to providing compassionate, personalized, and accessible care regardless of your ability to pay. Reach out today to learn more.
