How is Medicare Different from Medi-Cal?

Medicare and Medi-Cal are very different programs. Why is this important? Knowing the differences between what the programs will pay for and how to be eligible for benefits can have a huge financial significance for you and your loved ones, especially if you need long term care. We are going to review each program so that you know what is available to you and what your needs are.

What is Medicare?

Medicare is a federal health insurance program which mainly serves adults aged 65 and older. Medicare has four different parts, Part A, B, C, and D. Part A is Hospital Insurance, Part B is Medical Insurance, Part C is Medicare Advantage, and Part D is Prescription Coverage. You can have Part A and B without C and D. Part C is the one you typically see so many commercials on television for, as it is going through a provider for your coverage, which can offer additional benefits. You can choose between private providers to find the plan that is going to work best for you.

In terms of long term care, Medicare pays for little to nothing and only under very particular circumstances. Medicare will only pay for long term care after a minimum of a 3-day hospital stay. Then, they will only cover 20 days of a long term care facility. These 20 days will be 100% covered. After that, however, days 21-80 come at a hefty copay, around $150 a day, and you must be eligible for benefits. This means that if you are in a rehabilitation center receiving skilled nursing care, you must be making progress. When you stop making progress, Medicare stops paying. Medicare will also not pay any amount for custodial care, the type of care in which you may have in assisted living, a home health care aid, etc. These services must be paid either by supplemental insurance, out of pocket, or through Medi-Cal. If, however, you have another 3-day hospital stay, the clock will reset again.

Therefore, Medicare is only useful as health insurance and for short stays in skilled nursing facilities following a hospital stay. Medicare is not helpful for extended or permanent stays in long term care facilities.

What is Medi-Cal?

Medi-Cal, on the other hand, is also a federal program but run through the state of California. Medi-Cal provides coverage for those that meet the income and asset requirements. Medi-Cal can cover long term care. Long term care must be deemed medically necessary by a professional in order for them to cover a skilled nursing facility. There also may be a portion of the cost needed to be shared by the individual depending on the financial circumstances.

Medi-Cal can be a lifesaver to families, as long term care facilities can cost an exceptional amount of money. Beware, however, that while the family home can be exempt while a spouse is living in it, after death Medi-Cal can make a claim against the house to pay for expenses if the house is still in the Medi-Cal recipient’s name.

Medi-Cal, unlike Medicare, is also quite difficult to qualify and apply for. It is recommended that you consult an attorney before ever submitting an application to Medi-Cal, especially if there is property involved. Medi-Cal will be looking back into your finances and it is very easy to become disqualified for a period of time, making you responsible for the financial burden.

In Conclusion

Medicare and Medi-Cal can work together to provide you coverage. Medicare will pay first and focus on your hospitalization and health insurance needs, whereas Medi-Cal will assist you with long term care. Medicare will not pay for long term care. As stated above, it is strongly recommended that you meet with a lawyer before applying for Medi-Cal to discuss whether or not you qualify, how to spend down your assets, and how to protect the family home.