If your elderly parent has both Medicare and Medi-Cal, they are what the healthcare system calls “dual eligible” — and they have access to a more comprehensive set of benefits than most families realize.
Dual-eligible individuals represent about 12% of Medicaid enrollees nationally but account for a disproportionate share of healthcare spending, because they tend to have the highest needs. California has developed specific programs designed to better coordinate their care — and those programs translate into real, tangible benefits for home care.
Understanding the Two programs
Medicare is federal health insurance, primarily for people 65 and older. It covers hospital care, physician services, skilled nursing facility stays under specific conditions, and some home health services following a qualifying hospitalization.
What Medicare generally doesn’t cover: long-term personal care at home, homemaker services, non-medical supervision, and extended in-home care.
Medi-Cal is California’s Medicaid program and covers a broader range of long-term services and supports, including IHSS and — through CalAIM — Community Supports and Enhanced Care Management.
How Dual Eligibility Works Together
For dual-eligible individuals, Medicare is primary and Medi-Cal is secondary. Medicare pays first for covered services. Medi-Cal covers Medicare cost-sharing — premiums, deductibles, copayments — for qualifying individuals, which can represent significant savings. Medi-Cal also covers services Medicare doesn’t, particularly long-term personal care.
The net effect: a dual-eligible senior has more covered services, lower out-of-pocket costs, and access to care coordination programs designed specifically for their complexity.
pACE: The Most Integrated Option
The program of All-Inclusive Care for the Elderly is an intensive model specifically for dual-eligible adults who would otherwise qualify for nursing home level of care but prefer to remain in the community. pACE provides comprehensive medical, social, and personal care services through a day health center model, with in-home support as needed.
The Coordination Challenge
Navigating two systems simultaneously is complicated. Working with a care coordination service that understands both systems makes a concrete difference in what families are actually able to access.
Call Care partners for a free consultation about dual-eligible benefits and home care coordination in Orange County.