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Objectives This study quantifies income-related inequalities in health service utilisation of older rural-to-urban migrant workers, by comparison with older rural residents, and identify with factors giving rise to the inequalities.Setting Nationally representative survey conducted in 29 provinces, municipalities and autonomous regions of China.Participants 952 older rural-to-urban migrant workers and 2676 older rural residents were identified for further analysis.Main outcome measures The probability of 2 weeks outpatient utilisation and inpatient utilisation.Design Coarsened exact matching was used to control the confounding factors between older rural-to-urban migrant workers and their rural counterparts. Concentration index was used to depict the inequality in health service utilisation, and it can be decomposed proportionally into contributions.Results The concentration indices of 2 weeks outpatient utilisation of two groups were −0.2061 (95% CI: 0.0193 to 0.1364) and −0.2041 (95% CI: 0.0594 to 0.1469), respectively. The concentration indices of inpatient of two groups were −0.0024 (95% CI: −0.0047 to 0.0639) and −0.1412 (95% CI: 0.0235 to 0.1125), respectively. The contributors of the inequality of 2 weeks outpatient utilisation of two groups were poor self-assessed health (SAH) status and richest group. The contributors of the inequality of inpatient utilisation of the rural elderly were poor SAH, fair SAH and sense of happiness. The horizontal inequality indices for 2 weeks outpatient of two groups were 0.1321 and −0.0.992, respectively. The horizontal inequality indices for the inpatient of two groups were −0.0032 and −0.0396, respectively.Conclusions The results illustrated the existence of a socioeconomic gradient in health service utilisation between older rural-to-urban migrant workers and older rural residents. Our studies provided evidences to take full account of the health service needs, contributing to more reliable understandings of inequalities in the health service utilisation. The results may be referential to identify policy priorities conducive to the health policy reform in the process of active ageing in China.