Alyssa Lane
Medicare and Medicaid are two government-run programs designed to help cover health care costs for certain American residents. Medicare is a federal program that provides health coverage for people aged 65 and older and those with a disability, no matter their income level. On the other hand, Medicaid is a joint federal and state program that offers health coverage to individuals and families with limited incomes and resources. While Medicare is available to nearly every American aged 65 and above, Medicaid has stricter eligibility requirements that vary by state.
| Characteristics | Values |
|---|---|
| Number of people enrolled in Medicare and Medicaid in 1985 | Over 50 million |
| Percentage of people enrolled in Medicare and Medicaid in 1985 | More than one out of five |
| Number of people enrolled in Medicare Part A and Part B in 2022 | 59.6 million |
| Number of people enrolled in Medicaid and CHIP in November 2024 | 79,034,066 |
| Number of children enrolled in CHIP or enrolled in the Medicaid program in November 2024 | 37,517,916 |
| Percentage of people who report having Medicaid | 21% nationally |
| Number of people covered by Medicaid | 83 million |
| Percentage of births in the US covered by Medicaid | 41% |
| Percentage of children with special healthcare needs covered by Medicaid | Nearly half |
| Percentage of nursing home residents covered by Medicaid | 5 in 8 |
| Percentage of non-elderly adults with any mental illness covered by Medicaid | 29% |
| Percentage of non-elderly adults with HIV covered by Medicaid | 40% |
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What You'll Learn
Medicare eligibility
Medicare is federal health insurance for anyone aged 65 and over. Some people under 65 with certain disabilities or conditions may also be eligible for Medicare. These include End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant) and ALS (also called Lou Gehrig's disease).
Most people become eligible for Medicare three months before turning 65 and remain eligible for three months after turning 65. Some people get Medicare automatically, while others have to actively sign up—it depends on whether you start receiving Social Security benefits before you turn 65. If you qualify for premium-free Part A, you won't pay a monthly premium for this coverage. However, you will have to pay a premium for Part B coverage every month, even if you don't use any of the services. Monthly premiums for Part C and Part D coverage vary based on the plan you join and can change annually. You may also have to pay an additional amount each month based on your income.
To find out if you qualify for Medicare, you can visit Medicare.gov for more information on eligibility and enrollment. You can also use the Care Compare tool on the same website to find a doctor that accepts Medicare payments.
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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. While the federal government has general rules that all state Medicaid programs must follow, each state runs its own program, meaning eligibility requirements and benefits can vary.
Eligibility for Medicaid is generally determined by income level, with low-income families, pregnant women, children, and individuals receiving Supplemental Security Income (SSI) being mandatory eligibility groups. The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under 65, with eligibility extended to at least 133% of the federal poverty level (FPL). Most states have chosen to expand coverage to adults, and those that have not yet expanded may do so at any time.
Some states have more restrictive eligibility criteria, and certain groups, such as individuals who are blind, disabled, or 65 and older, may have their eligibility determined using the income methodologies of the SSI program. Additionally, states have the option to cover other groups, such as individuals receiving home and community-based services, children in foster care, and individuals with tuberculosis or end-stage renal disease who do not qualify for full coverage due to their immigration status.
To apply for Medicaid, individuals must find and check with their state's Medicaid agency to determine eligibility requirements and provide any necessary information or documentation.
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Medicare services
Medicare is federal health insurance for anyone aged 65 and older and some people under 65 with certain disabilities or conditions. It is recommended that people sign up for Medicare as soon as they are eligible to avoid a gap in coverage and/or late enrollment penalties.
There are several parts to Medicare:
- Part A covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.
- Part B covers medical services like doctors' services, outpatient care, and other medical services that Part A does not cover.
- Part D covers prescription drugs, including many recommended shots or vaccines.
Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for health and drug coverage. These "bundled" plans include Part A, Part B, and usually Part D. In many cases, you can only use doctors who are part of the plan's network. Plans may have different out-of-pocket costs than Original Medicare or supplemental coverage, and you may also have an additional premium.
You can request a replacement red, white, and blue Medicare card online using your personal Social Security account. To find a doctor that accepts Medicare payments, you can visit Medicare.gov and use the Care Compare tool.
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Medicaid services
Medicaid is a government health insurance program for people with very limited income and resources. It is not paid directly to the individual but rather sends payments to the health care provider. Medicaid can pay for medical services in a person's home or in a residential care facility.
In New York State, Medicaid offers an extensive dental plan for members, as well as a Doula Services Benefit, which includes coverage and higher reimbursement for doulas. The state also offers a Consumer Directed Personal Assistance Program (CDPAP), which allows members eligible for home care services to choose and hire their own caregiver or "personal assistant".
In Massachusetts, Medicaid and the Children's Health Insurance Program (CHIP) are combined into one program called MassHealth. MassHealth members may be able to get doctors' visits, prescription drugs, hospital stays, and other services.
Texas also offers Medicaid and CHIP, providing health coverage for low-income children, families, seniors, and people with disabilities.
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Dual eligibility
Medicare and Medicaid are two different government-funded healthcare programs. Medicare is a federal program for US citizens or legal residents aged 65 or older, younger people with disabilities, and people with end-stage renal disease or Lou Gehrig's disease. On the other hand, Medicaid is a joint federal and state program that provides health coverage for people with limited income and resources.
To be eligible for both Medicare and Medicaid, a person must qualify for either partial-dual or full-dual coverage. As of 2023, about 12 million people in the US were dually eligible for both programs. People who are dual-eligible may have chronic conditions and functional limitations that require more medical care.
If a person is dual-eligible, Medicare typically pays for health expenses first, and Medicaid may help pay for out-of-pocket and non-covered expenses. For example, Medicaid can pay for Medicare premiums, copays, coinsurance, and other out-of-pocket costs. Additionally, Medicaid covers long-term care, which Medicare does not, and may offer extra benefits such as hearing aids, eyeglasses, and dental exams.
The eligibility requirements for dual coverage depend on the state. Each state has its own Medicaid program with varying guidelines, income limits, and pathways to eligibility. For example, in Florida, an individual may qualify for dual coverage if they are single and earn less than $2,829 per month.
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Frequently asked questions
Medicare is a federal program that provides health coverage for individuals who are 65 or older, younger people with disabilities, and people with End-Stage Renal Disease. Medicare is available to nearly every American in the eligibility age bracket.
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. Medicaid is often a program of last resort for those without access to other resources.
Medicare is available based on age or disability and is not limited by income level. On the other hand, Medicaid is designed for people with very low incomes and resources and has strict eligibility requirements that vary by state. Medicare is the primary coverage provider for seniors and the disabled, while Medicaid is the primary payer of long-term care.
Yes, a person can be eligible for both Medicare and Medicaid. In such cases, Medicare pays first for Medicare-covered services, and Medicaid pays last, after Medicare and any other health insurance.
