Jeffrey Wade
Medicare and Medicaid are two different health insurance programs in the United States. Medicare is a federal health insurance program for people aged 65 and older, younger people with disabilities, and people with End-Stage Renal Disease. On the other hand, Medicaid is a joint federal and state program that provides health coverage for people with limited income and resources. Eligibility and benefits vary from state to state, and people who are dually eligible are enrolled in both programs. To determine whether you have Medicare or Medicaid, you can refer to the specific eligibility criteria and benefits offered by each program and understand how they differ.
| Characteristics | Values |
|---|---|
| Medicare | Federal health insurance for people aged 65 or older, younger people with disabilities, and people with End-Stage Renal Disease |
| Medicare Part A | Hospital Insurance that covers inpatient care in hospitals, critical access hospitals, and skilled nursing facilities |
| Medicare Part B | Medical Insurance that covers doctors' services, outpatient care, and other medical services that Part A doesn't cover |
| Medicare Part C (Medicare Advantage) | Private insurance plans that provide all of Part A and Part B coverage and typically offer extra benefits |
| Medicare Part D | Prescription Drug Coverage |
| Medicaid | A joint federal and state program that provides health coverage for certain individuals and families with low incomes and resources |
| Medicaid Coverage | Nursing home care, personal care services, emergency ambulance services, and dental services for people under 21 |
| Dual Eligibility | People who qualify for both Medicare and Medicaid are "dually eligible" and receive coordinated coverage from both programs |
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What You'll Learn
Medicare eligibility
Medicare is generally for people aged 65 or older. However, you may be eligible for Medicare earlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also known as Lou Gehrig's disease). If you are already receiving Social Security benefits before you turn 65, you will automatically get Medicare; otherwise, you will have to sign up for it.
If you qualify for retirement or disability benefits from Social Security (or the Railroad Retirement Board), you won't have to pay a premium for Part A coverage. This is known as "premium-free Part A". You will qualify for premium-free Part A if you meet the following criteria:
- You are already receiving retirement or disability benefits from Social Security or the Railroad Retirement Board.
- You will get Medicare before you turn 65.
- You or another qualifying person (such as your current or former spouse) paid Medicare taxes while working for a certain amount of time (usually at least 10 years).
If you don't qualify for premium-free Part A, you may be able to purchase it. You will need to pay a premium for Part B coverage every month, regardless of whether you use any Part B-covered services. If you have Medicare and also qualify for full Medicaid coverage, your state will pay your Medicare Part B monthly premiums. Depending on the level of Medicaid coverage you qualify for, your state might also pay for:
- Your share of Medicare costs, such as deductibles, coinsurance, and copayments.
- Part A (Hospital Insurance) premiums, if applicable.
People with both Medicare and full Medicaid coverage are considered "dually eligible". Medicare will pay first when you are a dual-eligible individual receiving Medicare-covered services, and Medicaid will pay after Medicare and any other health insurance you may have. If you are dually eligible, Medicare will cover your prescription drugs.
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Medicaid eligibility
Medicaid is a joint federal and state program that provides health coverage to Americans with limited income and resources. It is the single largest source of health coverage in the United States, covering over 77.9 million people.
Eligibility for Medicaid is determined by income and residency. Each state has its own rules for eligibility, and these rules vary considerably. Generally, eligibility is determined by income and residency, and some states also consider other factors, such as being a parent or having a disability.
Mandatory eligibility groups include low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI). States may also choose to cover other groups, such as individuals receiving home and community-based services and children in foster care.
The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state, and states were given the option to extend eligibility to adults with incomes at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may do so at any time.
To find out if you are eligible for Medicaid, you can apply to your state's Medicaid program. The best way to find out if you are eligible is to apply, and you can do this by contacting your state's Medicaid agency or creating an account with the Health Insurance Marketplace and filling out an application. If it looks like you qualify, your state agency will contact you about enrollment.
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Medicare coverage
Medicare is a federal health insurance program for people aged 65 and over, as well as some people under 65 with certain disabilities or end-stage renal disease.
There are several parts to Medicare coverage, with different parts covering different services. Medicare Part A, for example, covers inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (but not long-term care). It also helps cover hospice care and some home healthcare. Medicare Part B covers doctors' services, outpatient care, and other medical services that Part A does not cover. Part B is optional. Medicare Part D is prescription drug coverage. Since January 1, 2006, everyone with Medicare has had access to prescription drug coverage, regardless of income, health status, or prescription drug usage.
There are also Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," which are offered by private companies approved by Medicare. These plans may include Medicare drug coverage (Part D) and may be more cost-effective.
It is important to note that Medicare does not cover everything, and there may be out-of-pocket expenses for certain items or services. For example, Medicare does not cover long-term care, dentures, or routine physical exams. If you have Medicare and also qualify for full Medicaid coverage, your state may pay for your share of Medicare costs, deductibles, and copayments.
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Medicaid coverage
Medicaid is a federal-state program that provides health care coverage to people who qualify based on income and the value of their assets. It is jointly administered by the federal government and the states, with each state running its own program within federal guidelines. The federal government provides at least half of the funding for state Medicaid programs.
Medicaid offers benefits that Medicare does not usually cover, such as nursing home care and personal care services. People with Medicaid usually do not pay anything for covered medical expenses but may owe a small co-payment for some items or services.
Eligibility and benefits vary from state to state, and each state decides the full range of benefits it covers under Medicaid. However, federal law requires states to provide certain mandatory benefits, including inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, and dental services for people under the age of 21. States may also choose to offer other benefits and services, known as optional benefits, such as prescription drugs, case management, physical therapy, and occupational therapy.
Some states have expanded their Medicaid programs to cover all people below certain income levels, while others have expanded eligibility to include people with low incomes who may or may not have children. Even if you do not qualify for Medicaid based on income, you should still apply, as you may qualify based on other factors such as family status (including pregnancy or caring for young children), disability, or age.
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Dual eligibility
Medicare and Medicaid are two different government-funded healthcare programs. To be eligible for both, a person must qualify for either partial-dual or full-dual coverage. As of 2023, 12.5 million people in the United States are dually eligible for Medicare and Medicaid.
Partial-Dual Coverage
Partial-dual coverage depends on the support that a person receives from Medicaid. For example, if you have enrolled in Medicare and have limited income and assets, you may also be eligible for Medicaid.
Full-Dual Coverage
Full-dual coverage means that a person receives all the benefits of partial-dual coverage, plus additional benefits, such as long-term care services. Medicaid provides various programs based on a person's income compared to the Federal Poverty Level (FPL). For example, programs that help pay for prescription drugs.
How Dual Eligibility Works
Medicare will usually pay for health expenses first, and then Medicaid will cover any out-of-pocket or non-covered expenses. This includes paying Medicare premiums, copays, coinsurance, and other out-of-pocket costs. Medicaid may also offer additional benefits that Medicare does not, such as hearing aids, eyeglasses, and dental exams.
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Frequently asked questions
Medicare is federal health insurance for people aged 65 and older, as well as some people under 65 with certain disabilities or conditions. Medicaid, on the other hand, is a joint federal and state program that provides health coverage for people with limited income and resources.
Medicare is the primary payer and pays its portion first. Medicaid is the secondary payer and covers any remaining costs for items and services it covers. Medicare has four parts (A, B, C, and D) that help cover specific services, while Medicaid offers benefits that Medicare doesn't normally cover, such as long-term nursing home care and personal care services.
Medicare is available for people aged 65 or older, younger people with disabilities, and people with End-Stage Renal Disease. Most people are eligible for Medicare three months before turning 65 and three months after turning 65. Some people get Medicare automatically.
Eligibility for Medicaid is based on income and resources and varies from state to state. Contact your state's Medicaid office to learn more about eligibility and enrollment.
