Medicare vs. Medi-Cal: An Overview

Anyone who begins looking into long-term care options will quickly run into the terms Medicare and Medi-Cal. Many people confuse Medi-Cal and Medicare, but they are two different programs and unrelated. In today’s post, I will do my best to give you a basic overview of the two programs. In later posts, I will drill deeper into Medi-Cal’s benefit offerings, eligibility requirements and how you can prepare to enroll.

Medicare is a federal program that provides basic health insurance for everyone over age 65, and people under age 65 who are eligible for Social Security Disability benefits. Medicare is not based on financial need; anyone who meets the age, disability, and/or coverage requirements is eligible. Participants in the Medicare program are liable for premium payments, deductibles and co-payments.

Medicare has several parts:

  • Medicare Part A is Hospital Insurance
  • Medicare Part B is Medical Insurance
  • Medicare Part C (Medicare Advantage) is private insurance plans
  • Medicare Part D is Prescription Drug coverage

Medicare does not pay for long-term care. After a three-day hospital stay resulting from an illness or surgery, it will pay 100 percent of skilled nursing care, but only for the first 20 days. For days 21 through 100, it will pay a portion of the costs. After 100 days of skilled nursing care, Medicare stops paying altogether.
Medi-Cal is what we call the joint Federal-State Medicaid program in California (just like Covered California is what we call Obamacare in California). Medi-Cal and Medicaid are essentially the same thing. Medi-Cal is designed to pay medical costs for low-income persons of any age. Medi-Cal is a need-based program, meaning it is available to those who, regardless of age, meet the state’s financial eligibility and medical qualification requirements. Medi-Cal is a main source of financing for skilled nursing and long-term care in California.

Medi-Cal will cover most, if not all, of the cost of a skilled nursing facility, but only if a physician deems the care as “medically necessary.” In addition to skilled nursing costs, Medi-Cal covers what are called “essential health” care services, including doctor visits, hospital care, immunizations, some dental services, ambulance services, prescription drugs, lab tests, and some types of in-home care.

Medi-Cal Eligibility

To qualify for Medi-Cal, a person must be 65 or older or receiving Social Security Disability Insurance and have “countable” assets of $2,000 or less (or $120,000 if married). Meeting the state’s financial assets requirement is the most challenging aspect of Medi-Cal eligibility. In one of my other post, I will cover how Medi-Cal looks at your income and assets, explain terms like “spend down” and “look back,” and discuss how I can help you or your parents qualify for Medi-Cal.