Do you really know the differences between Medicare & Medicaid?

January 18, 2023

Medicare is a federal government health insurance program in which covered people share the cost of healthcare. Medicaid is a federal/state assistance program, and covered people typically don’t pay for it. Understanding how each works and which you might qualify for can be confusing.

Below, we tackle the key differences between these two types of coverage so that you can make an informed decision, whether you’re approaching retirement age or just curious about what kind of coverage your state provides through Medicaid.

What is Medicare?

Medicare is a federal government health insurance program that provides coverage for people who are 65 and older and some younger people with disabilities or other health conditions. Medicare has multiple parts and levels of coverage, and it can be particularly confusing to know which one to enroll in and when to enroll.

How does Medicare work?

People generally sign up for Medicare once per year. You’re first eligible to sign up three months before you turn 65, but you may be able to sign up earlier if you have a disability or other qualifying health condition, such as end-stage renal disease or ALS.^[1]

Generally, you’ll need to enroll in Medicare when you turn 65. But if you or your spouse is still working and have health insurance through an employer, the rules can be more complicated. It’s a good idea to check out the rules at Medicare.gov.

Check Out: How to Compare Medicare Advantage and Get the Best Plan

Who does Medicare cover?

Unlike health insurance plans from private insurers, you can’t purchase a Medicare plan for a couple or family — each eligible person must sign up for their own coverage.

Medicare is available to all eligible U.S. citizens and legal permanent residents, regardless of income. But you must have been a legal resident of the U.S. for at least five years to be eligible.^[2]

What does Medicare cover?

What’s covered by Medicare depends on which of the four parts of Medicare you enroll in:

Part A and Part B are referred to as Original Medicare. Part A covers hospital and hospice expenses and some home healthcare. Part B covers doctor visits, preventative care, and medical supplies. Typically, you can expect Medicare to cover about 80% of hospital and medical expenses. But Parts A and B don’t cover any prescription medications.^[3]^[4]
Part C is known as Medicare Advantage. This is a Medicare-approved health plan from a private insurance company. You can choose to have Medicare Advantage cover most of your Part A, Part B and Part D benefits instead of Original Medicare. It also offers some extra benefits not covered by Parts A and B, including vision, hearing, and dental services.
Part D provides prescription drug coverage. You can add Part D to Original Medicare or purchase it from a private Medicare Advantage insurer.

How much does Medicare cost?

Medicare costs depend on which parts you’re enrolled in and how long you (or your spouse) worked and paid Medicare taxes.

For 2023, the monthly premiums are:^[5]

Part A: $0 if you paid Medicare taxes long enough while working (usually at least 10 years). Either $278 or $506 per month if you don’t qualify for premium-free Part A, depending on how long you worked and paid Medicare taxes.
Part B: $164.90 or more per month, depending on your income.
Part C: Varies by plan
Part D: Varies depending on which plan you choose, but the average is around $43 per month

Important Information:

Like employer-sponsored health plans, Medicare has an open enrollment period. For Original Medicare, enrollment is from Oct. 15 to Dec. 7 each year. For Medicare Advantage, it’s Jan. 1 to March 31.

Check Out: The 10 Best & Worst Medicare Advantage Plans

What is Medicaid?

Through Medicaid, the federal government works with state governments to provide healthcare coverage for millions of children, pregnant women, seniors, and people with disabilities. It pays for medical care such as doctor visits, hospital stays, home health services, and lab fees. Medicaid may also cover prescription medications, physical therapy, and occupational therapy.

Unlike Medicare, you don’t have to be a senior citizen to qualify for Medicaid — you only need to meet your state’s requirements. Rules differ among states, but typically states consider family size and income when you apply for Medicaid.

How does Medicaid work?

Medicaid is administered on a state-by-state basis, and state eligibility requirements can vary widely.

To receive Medicaid, you typically need to submit an application through your state’s Medicaid agency or fill out an application through the federal Health Insurance Marketplace.^[6]

Depending on the state, you may also have to pay a small fee to apply.

Who does Medicaid cover?

Typically, you must be a low-income resident of the state that you’re applying for coverage in and meet other eligibility criteria. Some states also consider your age, household size, and whether you’re pregnant or have a disability to determine eligibility.

What does Medicaid cover?

The exact benefits available through Medicaid can vary greatly depending on your state. However, federal rules require all state Medicaid programs to cover hospital and doctor visits, laboratory and X-ray services, home health services, and nursing facility services. They’re also required to provide certain screenings, diagnostics, and treatments for children younger than 21.

States may also cover additional services, such as:

Prescription medications
Dental care and vision services
Hearing aids
Personal care services for seniors and people with disabilities

How much does Medicaid cost?

Most states don’t charge premiums for Medicaid coverage. However, some states may require recipients to share in the costs of some services, such as nonpreventive doctor visits, nonemergency visits to an emergency room, inpatient hospital visits, and prescription medications.

Learn More: How to Switch Back to Medicare from Advantage Plans

How Medicare and Medicaid are different

Medicare and Medicaid are two important health insurance programs, but they’re quite different in terms of the services they cover and their eligibility requirements. The following table provides a breakdown of the main differences between these two programs.

	Medicare	Medicaid
Eligibility	Available to people 65 and older or under 65 with certain disabilities or conditions, regardless of income.	Generally available to people with low income and resources, regardless of age, health, or disability status.
Coverage	Federally mandated standards for coverage. Typically does not cover long-term care services, such as nursing home or in-home support.	Some benefits are federally mandated, while others vary by state. Medicaid covers long-term care services in a nursing home and in-home care.
Cost	Most recipients pay monthly premiums, depending on how long they paid into Medicare and which coverage parts they select.	Recipients generally don’t pay monthly premiums but may be required to pay a small copay for some services.
How to Enroll	If you receive Social Security benefits, you’ll automatically be enrolled in Medicare Parts A and B when you turn 65. Otherwise, you can sign up for Medicare by visiting your local Social Security office, calling the SSA at 1 (800) 772-1213, or applying online at www.ssa.gov.	Apply for Medicaid by contacting your state Medicaid agency or by filling out an application through the federal Health Insurance Marketplace.

Can you have both Medicare and Medicaid?

In some cases, someone may be eligible for both Medicare and Medicaid at the same time. This is known as a dual eligibility status, or “dually eligible” for short.

Generally, this happens when someone qualifies for Medicare based on their age or disability status and Medicaid due to their financial circumstances.

Dual health plans: What to know

When someone is dually eligible, Medicare pays first for any covered services, and Medicaid pays after all Medicare and private health insurance benefits have been exhausted. As a result, they usually won’t have any out-of-pocket healthcare costs.

While dual eligibility can provide access to more comprehensive coverage and lower out-of-pocket costs, there are also some potential drawbacks. For example, because Medicaid benefits vary by state, recipients may have difficulty navigating each program’s rules and requirements.

Additionally, navigating the complex relationships between Medicare and Medicaid can be challenging, particularly if a provider or other service doesn’t recognize both your coverage sources.

This article originally appeared on Insurify.com and was syndicated by MediaFeed.org.