Jane Dotson
Medicare and Medicaid are government-funded insurance programs in the United States. Medicare is a federal insurance program for people over 65 and some people under 65 with certain disabilities. It consists of several parts, including Original Medicare (Part A and Part B) and Medicare Advantage, which bundles Parts A, B, and usually Part D into one plan. Medicaid is a joint federal and state program that provides free or low-cost health coverage to certain low-income individuals, families, children, pregnant women, the elderly, and people with disabilities. Each state has its own Medicaid program but must follow federal guidelines, and the federal government provides at least half of the funding.
| Characteristics | Values |
|---|---|
| Medicare definition | Federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions. |
| Medicare Part A | Covers inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. |
| Medicare Part B | Covers medical services like doctors' services, outpatient care, and other medical services that Part A doesn't cover. |
| Medicare Part D | Prescription Drug Coverage. |
| Medicare Advantage Plan | Another Medicare health plan choice, sometimes called "Part C" or "MA Plans," offered by private companies approved by Medicare. |
| Medicaid definition | A joint federal and state program that gives health coverage to some people with limited income and resources. |
| Medicaid coverage | Emergency Ambulance services, dental services for people under 21, health coverage for some individuals and families, including children, parents, pregnant women, elderly people with certain incomes, and people with disabilities. |
| Medicaid and CHIP enrollment (Dec 2024) | 37,315,827 children enrolled in the Medicaid program, representing 47.5% of total enrollment. |
| Medicare enrollment (March 2023) | 65,748,297 people enrolled in Medicare. |
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What You'll Learn
Medicare eligibility and enrollment
Medicare is the health insurance programme for individuals aged 65 or older or those with specific disabilities or permanent kidney failure. The eligibility and enrollment criteria for Medicare are as follows:
Eligibility
Most people are eligible for premium-free Part A (Hospital Insurance), which can be claimed based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage and file an application for Social Security or Railroad Retirement Board (RRB) benefits.
For Part B (Medical Insurance), individuals must meet additional criteria. They must be a U.S. resident and either a U.S. citizen or a lawful permanent resident who has resided in the country for five continuous years before applying for Medicare.
Enrollment
Enrollment in Medicare Parts A and B is generally available starting three months before an individual turns 65 and ending three months after their 65th birthday. This is known as the Initial Enrollment Period. Coverage always starts on the first day of the month.
Individuals already receiving Social Security or RRB benefits before turning 65 are often automatically enrolled in premium-free Part A and Part B. They have the option to refuse Part B coverage. However, those who are not automatically enrolled, including individuals not receiving Social Security or RRB benefits, must actively sign up during their Initial Enrollment Period.
If an individual misses their Initial Enrollment Period, they may have to pay a monthly late enrollment penalty for Part B coverage during the next available enrollment period. This penalty increases the longer one waits to sign up.
There are also Special Enrollment Periods available for certain situations, such as when an individual stops working or loses job-based health coverage. This Special Enrollment Period typically lasts for eight months, and individuals can sign up for Part B during this time.
It is important to note that Medicare coverage options and enrollment periods can vary based on individual circumstances, and there may be exceptions or additional criteria to consider.
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Medicare Part A
Medicare is federal health insurance for anyone aged 65 and older and some people under 65 with certain disabilities or conditions. Most people receive Medicare Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. Those who worked and paid Medicare taxes for at least 10 years are eligible for premium-free Part A. Additionally, individuals who receive regular dialysis treatments or a kidney transplant and meet certain conditions are eligible for premium-free Part A.
Part A covers inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. To receive the benefits of Part A, certain conditions must be met.
If an individual is receiving monthly Social Security or Railroad Retirement Board (RRB) benefits, they do not need to file a separate application to become entitled to premium-free Part A. In this case, the individual will start receiving Part A automatically when they turn 65. However, if an individual is not receiving monthly Social Security or RRB benefits, they must file an application for Medicare by contacting the Social Security Administration. Part A coverage begins the month the individual turns 65, provided they file an application for Part A or for Social Security or RRB benefits within 6 months of turning 65. If the application is filed more than 6 months after turning 65, Part A coverage will be retroactive for 6 months.
For individuals who must pay a premium for Part A, they must file an application to enroll by contacting the Social Security Administration and also enroll in or already have Part B. To keep premium Part A, the individual must continue to pay all monthly premiums and stay enrolled in Part B. This means that the person must pay both the premium for Part B and the premium for Part A to maintain coverage. Premium Part A coverage begins the month following the month of enrollment.
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Medicare Part B
Medicare is federal health insurance for anyone aged 65 and older and 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 to people with limited income and resources.
If you use an insulin pump that's covered under Part B's durable medical equipment benefit, or you get your covered insulin through a Medicare Advantage Plan, your cost for a month's supply of insulin for your pump is capped at $35. If you have Part B and Medicare Supplement Insurance (Medigap) that pays your Part B coinsurance, your Medigap plan should cover the $35 (or less) cost for insulin.
If you already have Part A, you can add Part B during specific enrollment periods. If you've been covered by an active employer group health plan (either yours or your spouse's) since turning 65, and it ended within the last 8 months, you can enroll in Part B without any penalty during a "Special Enrollment Period." This period is available at any time of the year.
To learn more about enrolling in Medicare, you can refer to the "Medicare & You" handbook, call Social Security at 1-800-772-1213, or visit your local Social Security office.
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Medicare Part C (Medicare Advantage)
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare, which is administered by the federal government. Part C plans are offered by private, Medicare-approved insurance companies. They provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage and typically include extra benefits such as vision, hearing, dental, and/or health and wellness programs.
Medicare Advantage plans can be customized to meet specific needs and treat certain conditions and diseases. They may also include prescription drug coverage (MAPD plans). If you require prescription drug coverage with Original Medicare, you would need to purchase Medicare Part D separately.
Medicare Advantage plans vary in cost. They often have premiums, deductibles, and copays, and these can differ from plan to plan and state to state. The projected average premium for a Medicare Advantage plan in 2025 is $17 per month. However, there is a cap on out-of-pocket expenses for Part C-covered services, meaning you won't pay anything for the rest of the year once you reach this limit.
You can enroll in a Medicare Advantage plan during your Initial Enrollment Period (IEP) for Medicare, which begins three months before you turn 65 and ends three months after your 65th birthday. If you already have Original Medicare and want to switch to Medicare Advantage, or if you are already enrolled in a Medicare Advantage plan and want to change to a different one, you can do so during the Annual Enrollment Period (AEP), which runs from October 15 to December 7.
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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 largest source of health coverage in the United States, with over 77.9 million beneficiaries.
While Medicaid is a federal program, each state has its own requirements and income limits for eligibility. Some states have chosen to expand coverage to adults, while others have not. To determine eligibility, individuals should check with their state's Medicaid agency.
In addition to income, other factors that may affect Medicaid eligibility include age, blindness, disability, and immigration status. Individuals aged 65 and older, or those who are blind or have a disability, may have their eligibility determined using the income methodologies of the SSI program. Families that include non-US citizens can also apply for Medicaid, and applying will not affect their immigration status or chances of becoming permanent residents or citizens.
The Children's Health Insurance Program (CHIP) is another option for children whose families have slightly higher incomes that exceed the Medicaid eligibility threshold. CHIP qualifications vary by state, and each state sets its own income limits.
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Frequently asked questions
Medicare is federal health insurance for anyone aged 65 and over and some people under 65 with certain disabilities.
Medicare Part A covers inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. It also helps cover hospice care and some home health care.
Medicare Part B covers medical services like doctors' services, outpatient care, and other medically necessary services that Part A doesn't cover.
Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The eligibility rules differ across states.
Medicaid covers emergency ambulance services, dental services for people under 21, and health coverage for some individuals and families, including children, parents, pregnant women, elderly people with certain incomes, and people with disabilities.
