Medicare Part D and Dual Eligibles: A Guide for California Advocates

I. A Quick Glance at Medicare Part D 

This section of the manual is intended for those seeking a brief overview of the program. Advocates who are unfamiliar with the program or with California healthcare programs may find this section useful. For a more in-depth discussion of the particulars of Medicare Part D, please proceed to the next section. 
 
Basic Definitions You Will Need to Know 
Is Medicare the same as Medi-Cal? 
No. Medicare is a healthcare program financed by the federal government. In general, Medicare is available to people who are 65 or older or who have a permanent disability. Medicare is available regardless of a person?s income or assets. A person usually must have a work history in order to qualify for Medicare. A person applies for Medicare through a local Social Security Administration office. 

Medi-Cal = Medicaid ? Medicare

Medi-Cal is California?s version of the Medicaid program. Medicaid is a healthcare program administered jointly by both the federal and state governments. The federal government pays for about half of all of Medi-Cal?s costs. Medi-Cal beneficiaries are generally 65 or older or have a disability, like Medicare beneficiaries, but Medi-Cal beneficiaries also include children, families with children, and pregnant women. A person must have a low income and limited assets to be eligible for Medi-Cal. A person may apply for Medi-Cal through a county welfare office or by completing the joint Healthy Families/Medi-Cal application and sending it to the state?s Single Point of Entry in Sacramento. SSI and CalWORKs recipients in California automatically receive Medi-Cal without the need to complete a separate application. 
 
What are Medicare Parts A, B, and C? 
Medicare Part A generally covers healthcare provided in a hospital, nursing facility or home health care following a hospitalization, some therapies, tests and lab work, hospice care, and kidney dialysis. Prescription drugs provided in a hospital setting generally are paid for by Part A. Most people do not have to pay a premium for Part A coverage. Part A does not cover 100% of the cost of hospitalization, and it covers a limited number of days in a hospital. 
Medicare Part B generally covers out-patient services, doctor visits, durable medical equipment, prosthetic devices, some home health care, and some preventive care. When people enroll in Part A, they are generally enrolled in Part B as well, though a person may opt out of Part B. Part B requires payment of a monthly premium which may be deducted from a Social Security check. Low income people can apply at county welfare offices for programs that pay the Part B premiums. (See ?What are Medicare Savings Programs?? below). Drugs such as injections administered in a doctor?s office, including vaccinations, are covered under Part B.

Medicare Part C pertains to the provision of Medicare services by private managed care plans. Some private companies are paid by the Medicare program to provide care to Medicare beneficiaries through HMOs or PPOs. This program is currently called ?Medicare Advantage.? You may come across pre-2004 documents referring to the program as ?Medicare + Choice.? 
 

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