Orlando Harmon
Medicare and Medicaid are both U.S. government-sponsored programs that provide health care coverage to certain American residents. Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. On the other hand, Medicaid is a joint federal and state program that provides health coverage for people with low incomes, including families, children, pregnant women, the elderly, and people with disabilities. While Medicare is the primary payer for services it covers, such as doctors' visits and hospital care, Medicaid can serve as secondary insurance, covering Medicare cost-sharing like coinsurance and copays. This dynamic of Medicare and Medicaid working together is especially relevant for individuals eligible for both programs, known as dual-eligibles.
| Characteristics | Values |
|---|---|
| Medicare eligibility | People aged 65 or older, younger people with disabilities, and people with End Stage Renal Disease |
| Medicaid eligibility | Low-income individuals and families, children, parents, pregnant women, elderly people with certain incomes, and people with disabilities |
| Medicare coverage | Doctors' services, outpatient care, and other medical services |
| Medicaid coverage | Nursing home care, personal care services, doctors' visits, hospital care, home care, skilled nursing facility care, emergency ambulance services, and dental services for people under 21 |
| Medicare costs | Medicare Part C plans may have lower out-of-pocket costs than Original Medicare plans |
| Medicaid costs | People with Medicaid usually don't pay anything for covered medical expenses but may owe a small co-payment for some items or services |
| Medicare insurance companies and Medicaid | If eligible for both, Medicare is the primary payer and Medicaid is the payer of last resort; Medicaid may cover Medicare cost-sharing, including coinsurance and copays |
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What You'll Learn
Medicaid covers services Medicare doesn't
Medicare and Medicaid are two different programs that help cover medical costs. Medicare is a federal program that primarily covers people over the age of 65, younger people with disabilities, and people with End-Stage Renal Disease. On the other hand, Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The eligibility requirements and benefits covered under Medicaid can vary from state to state.
Medicaid offers benefits that are not normally covered by Medicare. These include:
- Nursing home care
- Personal care services
- Cost-sharing for Medicare-covered services, including coinsurance and copays
- Premium assistance: If you have both Medicare and Medicaid, you will likely be automatically enrolled in a Medicare Savings Program (MSP)
- Coverage for certain drugs that Medicare doesn't cover
If you have both Medicare and Medicaid, Medicare will pay for your Medicare-covered services first, and Medicaid will pay last, covering any cost-sharing responsibilities you may have.
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Eligibility for Medicaid and Medicare
Medicare is a federal insurance program for individuals aged 65 and older and certain people under 65 with disabilities or specific conditions. Eligibility and enrollment for Medicare are handled by the Social Security Administration, which can be contacted at 1-800-772-1213. Medicare is typically the primary payer for those with dual eligibility.
Medicaid, on the other hand, is a joint federal and state program that provides health coverage for specific low-income individuals, families, children, pregnant women, seniors, and people with disabilities. Eligibility rules for Medicaid vary across states, and individuals must meet their state's criteria for income, resources, and residency. Some states allow individuals to “spend down” their income to qualify for Medicaid by paying non-covered medical expenses and cost-sharing.
To determine eligibility for Medicaid, individuals should contact their State Medical Assistance (Medicaid) office or their local Medicaid office. They can also visit the Medicaid website for more information. If eligible for both Medicare and full Medicaid coverage, individuals are considered ""dually eligible." In such cases, Medicare typically pays first for Medicare-covered services, while Medicaid pays last, covering any remaining cost-sharing.
It is important to note that Medicaid offers benefits that Medicare does not, such as nursing home care and personal care services. Additionally, individuals with dual eligibility may be automatically enrolled in a Medicare Savings Program (MSP) or a special Medicare Advantage Plan to help manage their coverage and costs.
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Medicaid as secondary insurance
Medicaid is a federal-state program that helps cover medical costs for people with limited incomes and resources. Each state has its own eligibility criteria and coverage specifics. For instance, some states allow you to "spend down" your income to qualify for Medicaid. This is done by paying non-covered medical expenses and cost-sharing until your income is lowered to a level that qualifies you for Medicaid.
Medicaid can act as secondary insurance for individuals who have Medicare as their primary insurance. In such cases, Medicare pays first for services it covers, such as doctors' visits, hospital care, home care, and skilled nursing facility care. Then, Medicaid may cover the remaining Medicare cost-sharing, including coinsurance and copays. This is known as "wrap-around coverage."
Medicaid beneficiaries may have other sources of coverage, such as private insurance, Medicare, or other public programs. In these cases, Medicaid interacts with these payers and may provide supplemental coverage for services not fully covered by the primary insurance.
It's important to note that Medicaid enrollees must identify potential third-party sources of coverage and assign the Medicaid agency the right to pursue third-party liability on their behalf. States are responsible for ascertaining the legal liability of third parties and ensuring compliance with the requirements of the Medicaid program.
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Medicare cost-saving programs
Medicare Savings Programs (MSPs) are cost-saving programs that help pay for Medicare costs for people with limited incomes and savings. These programs are run by individual states and have different eligibility requirements and benefits in each state.
There are three main types of MSPs:
- Qualified Medicare Beneficiary (QMB): Covers Medicare Parts A and B premiums. If you have QMB, you should not be billed for Medicare-covered services when seeing Medicare providers or providers in your Medicare Advantage Plan’s network.
- Specified Low-income Medicare Beneficiary (SLMB): Covers Medicare Part B premium.
- Qualifying Individual (QI) Program: Covers Medicare Part B premium.
There is also a fourth type of MSP, the Qualified Disabled Working Individual (QDWI) program, which covers the Medicare Part A premium.
If you have enrolled in an MSP, you will automatically get Extra Help, a federal program that helps pay for your Medicare prescription drug (Part D) plan costs. For example, in 2025, you will pay no more than $12.15 for each drug covered by your Medicare drug plan.
Medicaid is another cost-saving program that can help cover medical costs for people with limited incomes and resources. It is a joint federal and state program, with eligibility and coverage specifics varying by state. If you qualify for Medicaid, it may help pay for costs and services that Medicare does not cover. For example, Medicaid can provide secondary insurance for services covered by both Medicare and Medicaid, such as doctors' visits, hospital care, home care, and skilled nursing facility care.
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Medicaid eligibility for children
Medicaid is a federal-state collaboration that assists in covering medical expenses for people with limited income and resources. The eligibility criteria for Medicaid differ across states, and each state offers a range of Medicaid programs. While Medicare is the primary payer for services covered by both Medicare and Medicaid, Medicaid acts as a secondary insurance provider, covering Medicare cost-sharing, including coinsurance and copays.
Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including children from low-income families. CHIP is available in every state, and each state program determines eligibility. CHIP provides low-cost health coverage to children whose families earn too much to qualify for Medicaid but still need assistance.
Infants born to low-income pregnant women are automatically eligible for Medicaid or CHIP for the first year of their life. After this period, they may still be eligible for CHIP. Children must meet financial and non-financial criteria to be eligible for CHIP. Financial eligibility is determined by Modified Adjusted Gross Income (MAGI), which is used to assess eligibility for Medicaid, CHIP, and premium tax credits. CHIP beneficiaries must also be state residents.
CHIP-funded Medicaid expansions provide coverage for children under 19, and some states cover children up to the age of 2, or even 19, depending on the county. These eligibility standards include CHIP-funded Medicaid expansions for children under 19, who may be covered under the mandatory children's group or the optional targeted low-income child group.
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Frequently asked questions
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources.
Medicaid covers health costs for people with low incomes. It also covers nursing home care, personal care services, and non-emergency medical transportation.
Eligibility for Medicaid varies from state to state. It depends on your income and resources, with each state having a different resource limit.
To apply for Medicare, visit Medicare.gov for more information on eligibility and enrollment. To apply for Medicaid, contact your state's Medicaid agency or your State Medical Assistance (Medicaid) office.
