Understanding Your Medicare & Medi-Cal Options

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 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 and/or resources (assets). Some people qualify for both Medicare and Medi-Cal.

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

Current Medi-Cal Cards
Older Medi-Cal Card, still accepted

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 and resource levels 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

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 referrals 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.

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.
  • In Orange County, Medicare Advantage 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.

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

Medicare is working with some states and health plans to offer demonstration plans for certain people who have both Medicare and Medi-Cal. California is one of these states.

Option 3: Cal MediConnect (Medi/Medi)

What is Cal MediConnect?

Cal MediConnect is a type of health care plan that promotes coordinated healthcare and long-term services and supports (LTSS) for seniors and people with disabilities who are eligible for both Medicare and Medi-Cal, sometimes referred to as “dual eligible beneficiaries” or “Medi-Medis”.

What Cal MediConnect (CMC) Plans are available in Orange County?

The CMC plan for Orange County residents is OneCare Connect, offered by Cal Optima. This plan combines your Medicare and Medi-Cal services into one plan with additional benefits, including transportation, vision, dental, and care coordination.
With all your health and home care services coordinated together, members have one card to present at medical appointments and one phone number to call with any questions.

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.
    — Exception: Medi/Medi’s may join or leave OneCare Connect at any time

We Can Help

Call HICAP for additional information or counseling services

(800) 434-0222 HICAP Hotline
(714) 560-0424 for Orange County
(909) 256-8369 for San Bernardino & Riverside Counties
(760) 267-1191 for Inyo and Mono Counties

Health Insurance Counseling & Advocacy Program
Services also available in Spanish, Vietnamese, Korean, and Chinese
HICAP does not sell or endorse any insurance products
SHIP State Insurance Assistance Program

The project described was supported by Funding Opportunity Number CMS-1J1-19-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

This project is funded in part through a grant from the California Department of Aging, as allocated by the Orange County Board of Supervisors and administered by the Office on Aging.