The Coverage That Becomes a Maze

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Since I began working in health care advocacy more than a decade ago, one demographic group has stood out as uniquely vulnerable to system complexities and gaps in care: People who qualify for both Medicare and Medi-Cal, California’s Medicaid program. These “dually eligible enrollees” include people ages 65 or older with limited incomes as well as younger people who qualify for Medicare because of a disability.

In theory, this group has more coverage than most. In practice, these two programs were never designed to work together smoothly, and the resulting structural barriers can impede and delay care.

Seemingly benign administrative errors can trigger the termination of Medi-Cal benefits, freezing access to essentials like medical transportation or a home care aide. System oversights generate medical bills that should not exist. Bureaucratic delays accelerate decline, forcing preventable transfers to nursing homes.

A lapse in Medi-Cal coverage for dually eligible enrollees can mean the difference between life and death.

At Justice in Aging, a national organization that uses the power of law to fight poverty among older adults, we see these failures as symptoms of a larger structural dysfunction that erodes trust in health care among those who need it most. California’s 1.8 million dually eligible enrollees are among the state’s most medically complex residents. Two-thirds are people of color and most live with complex conditions.

Navigating the maze to access care and services can feel impossible. Medi-Cal and Medicare have different enrollment criteria, and they offer some overlapping yet distinct services. They are overseen by separate state and federal agencies. Medicare is this group’s primary source of medical care, while Medi-Cal provides personal care services, long-term care, and other benefits that help people remain at home as they age.

Day to day, dually eligible enrollees shoulder the administrative burdens of two separate coverage sources. Accessing and renewing benefits involves daunting paperwork to prove eligibility. Countless opportunities for errors result from the fact that older adults overwhelmingly renew their Medi-Cal coverage manually. They fill out paper forms and mail them to county agencies. Simple mistakes such as scanning forms improperly can disenroll someone entirely.

The effects are striking. In January 2026, younger Medi-Cal enrollees were 50 times more likely to have coverage automatically renewed by the state than were older adults and people with disabilities. And one-quarter of all renewals in the Medi-Cal category that includes dually eligible enrollees ended in terminations. Of those terminations, 96% occurred not because a person was ineligible, but because of procedural issues such as incomplete paperwork or outdated mailing addresses.

Predictions of Administrative Failures

While some eventually re-enroll, even a short lapse in coverage may result in catastrophic medical bills or lost access to critically needed supports like In-Home Supportive Services.

These procedural terminations will only worsen as the 2025 federal budget law H.R. 1 is implemented. While H.R. 1’s work requirements do not directly apply to this dually eligible group, the law’s sweeping eligibility restrictions will create massive administrative bottlenecks for California’s overburdened frontline reviewers of Medi-Cal eligibility. As counties stretch to capacity, slowdowns and mistakes will proliferate.

People who follow every instruction, keep up with appointments and prescriptions, and work hard to stay covered shouldn’t be penalized for missed paperwork or an agency’s mistake. When that happens, they feel misled and mistreated by a system that doesn’t seem to care. Their sense of disenfranchisement is worsened by the fact that it takes a dedicated advocate to overcome some of these structural barriers and untangle the bureaucratic communication.

People who follow every instruction, keep up with appointments and prescriptions, and work hard to stay covered shouldn’t be penalized for missed paperwork or an agency’s mistake. When that happens, they feel misled and mistreated by a system that doesn’t seem to care.

Doing Everything Right Is Not Enough

I remember one dually eligible enrollee who was set for hospital discharge and needed rehabilitative care. Medicare and Medi-Cal failed to coordinate, leaving his family responsible for temporarily transitioning him to a nursing facility, ensuring he received appropriate rehabilitative services, and arranging in-home care. They were neither trained nor prepared for such a vast undertaking. Despite having more coverage than most, this enrollee got the care he needed only because of his family’s persistence.

Further complicating matters, efforts to re-enroll unfold against a backdrop of medical bills that providers often improperly send straight to dually eligible patients. This alone erodes trust in the system among older adults, who we know prioritize knowing out-of-pocket costs upfront. Many older adults with low incomes wind up paying these large bills out of pocket for fear their provider will stop seeing them.

Their anxieties are warranted. Despite Medicare’s favorable rates, some providers refuse to see dually eligible enrollees at all because they are dissatisfied with how Medi-Cal coverage of non-covered Medicare costs works. This exacerbates existing provider shortages in rural areas, where older adults might wait months and travel long distances to use programs they have paid taxes for decades to support. It becomes glaringly clear to them that the system was never designed to meet all their needs.

Bridging the Bureaucratic Chasm

Because Medi-Cal and Medicare are so complicated, even the smallest delay or mistake produces a cascade effect.

One of my clients whose stroke left him with limited mobility waited more than a week for critical medical equipment because an administrative error stalled approval of the provider’s prescription. After days of frustration and phone tag with the provider, the equipment was finally approved. But in the interim, my client could not move around without assistance.

For people with disabilities, a week without the right equipment is not an inconvenience. It is a week of lost function that may never come back.

Continuing to choose complexity over care is a policy decision with human costs. California can already access the data it needs to renew most older adults’ Medi-Cal coverage automatically. The state should strive to maximize use of this information, so no one loses coverage for simple paperwork reasons — especially when the methods to do so are readily available.

Procedural errors should be treated as system failures, not mistakes made by enrollees. Medicare and Medi-Cal must work together to share data, speak with one voice, and reach out to enrollees to prevent coverage lapses instead of reacting to them. For dually eligible enrollees, the stakes could not be higher.