En español | Because of the similarity in their names, Medicare and Medicaid are often confused. But these two government health insurance programs are very different.
Medicare is a federal government program that covers medical expenses for more than 63 million Americans 65 and older as well as younger people who qualify because of a disability. Medicare eligibility is not based on your income or assets, and you can’t be denied coverage or charged more because of your existing medical conditions.
Medicaid, which federal and state governments run jointly, provides health care and long-term care coverage for more than 72.5 million Americans, including children, parents, low-income adults, older adults and people with disabilities. The government sets general standards for Medicaid, but specific eligibility requirements and coverage details vary by state. Your income and assets must fall below certain levels to qualify.
The Medicare and Medicaid programs were both established July 30, 1965, when President Lyndon Johnson signed the Medicare and Medicaid Act — also known as the Social Security Amendments of 1965 — into law. Medicare was created as a health insurance program for older Americans, while Medicaid provides health insurance for people with limited incomes. Eligibility and coverage for both programs have expanded since they began.
Medicare recipients can use any doctor or hospital in the United States that participates in the Medicare program, which covers a vast majority of providers. Original Medicare includes Part A and Part B:
But Medicare doesn’t cover everything. You’ll have to pay deductibles and copayments for Part A and Part B. The program also doesn’t cover most dental, hearing and vision care expenses. And it won’t cover long-term care, other than short-term stays in a skilled nursing facility for rehabilitation after an eligible hospital stay.
Many people with original Medicare buy a private Medicare supplement policy, also known as Medigap, to cover out-of-pocket expenses beyond what Medicare covers.
You can add drug coverage. Medicare doesn’t automatically cover medications, but you can buy a Part D prescription policy from a private insurance company to help cover those costs.
Another coverage option: Some people choose to get coverage from a private Medicare Advantage plan rather than original Medicare. These plans, which insurers also sell, must provide the same coverage as Medicare Part A and Part B, but they may have different deductibles and copayments.
Most Medicare Advantage plans also cover prescription drugs and provide some dental, hearing and vision care. You must enroll in Medicare Part A and Part B, and pay required premiums, even if you choose to buy an Advantage plan. Some plans have monthly premiums on top of Part A and B premiums.
You can qualify for Medicare coverage in two ways:
If you’re age 65 or older. You can qualify for Medicare at age 65 if you’re a U.S. citizen or permanent legal resident who has lived in the United States for at least five years.
If you’re younger than 65. You can qualify for Medicare before age 65 if you’re disabled or meet certain conditions, such as:
Medicare isn’t free. Most people don’t pay premiums for Part A because they or their spouse paid Medicare payroll taxes when working for at least 40 calendar quarters. That’s 10 years total, but the work doesn’t have to be continuous.
Otherwise for Part A, you’ll pay $274 a month in 2022 ($278 in 2023) if you or your spouse paid Medicare payroll taxes for 30 to 39 quarters or $499 a month ($506 in 2023) if you or your spouse paid Medicare taxes for fewer than 30 quarters.
For Part B, most people pay $170.10 a month in 2022 ($164.90 in 2023). People with higher incomes pay more.
If you’ve been receiving Social Security or Railroad Retirement Board benefits for at least four months before your 65th birthday, you’ll be enrolled automatically in Medicare. Your coverage begins the first day of the month you turn 65. If your birthday falls on the first day of a month, such as May 1, your coverage will start a month earlier.
If you’re not yet receiving Social Security benefits, you’ll need to take steps to enroll in Medicare. You can sign up during your initial enrollment period, which begins three months before the month you turn 65 and ends three months after your birthday month. So, if your birthday is May 1, you’re eligible to enroll from Feb. 1 to Aug. 31.
If you or your spouse is still working and you have health insurance from your employer, you may delay signing up for Medicare while you have that coverage. Otherwise, you need to enroll at 65 to avoid coverage gaps or late enrollment penalties.
Low-income Americans of any age with Medicaid receive comprehensive health care, including doctor services, home health care, inpatient and outpatient hospital care, lab tests and X-rays, and rural health clinic services. People who meet additional requirements will qualify for nursing home care.
Other coverage varies by state. Some state Medicaid programs also cover dentistry, physical and occupational therapy, prescription drugs, vision services, and some personal care services such as help with bathing, dressing and going to the bathroom.
Some state Medicaid programs also offer home- and community-based service (HCBS) waiver programs that let you receive care at home or in an assisted living facility rather than in a nursing home. These waiver programs vary significantly by state.
Typically, you must apply for a waiver and meet income and asset levels. Medicaid waiver programs may also have separate requirements for different coverage levels, based on how much help you need with activities of daily living, such as bathing, dressing or eating.
Qualifying for Medicaid depends on your household income, age, disability or family size. Specifics vary by state, but annual income below a certain level is the first step. You may also need to have few financial assets, depending on your age, state and other factors.
You can get a quick estimate of Medicare eligibility based on your state and income and the size of your household by using the eligibility tool at HealthCare.gov. Even if you don’t qualify for Medicaid based on your income, you may still be eligible if you have children, have a disability or are pregnant.
Contact your state Medicaid office for more information. Listings below the map include contact information for U.S. territories.
Those 65 or older, blind or disabled have different requirements. Eligibility is based on income and assets, and an individual generally can keep up to $2,000 in countable assets to qualify. Some states allow you to keep more.
Most states exempt a primary residence, one car and prepaid burial expenses from the countable assets. Some trusts and other assets may be exempt, depending on the state. If one spouse needs long-term care but another spouse continues to live at home, the asset limits are higher for the “community spouse” still at home.
The answer depends on where you live. Federal regulations allow states to pass along small charges as copayments, coinsurance, deductibles and sometimes premiums.
But the government limits those charges based on your income. And if you need emergency services, states can’t require you to share the costs of that care.
You can apply for Medicaid at any time, unlike Medicare’s initial open enrollment periods, either through your state Medicaid agency or by submitting a form through the federal government’s Health Insurance Marketplace. If the marketplace determines that you or someone in your household qualifies for Medicaid, it will forward the information to your state agency.
More than 12 million people, called “dual eligibles,” qualify for both Medicare and Medicaid at the same time.
If you qualify for both programs, Medicare will pay covered expenses first. Then Medicaid will fill in some gaps, such as the Medicare Part A and Part B deductibles, copayments and coinsurance. If you qualify for Medicaid, you’re automatically enrolled in the Extra Help program that helps pay Part D premiums, deductibles and copays for prescription drugs.
Medicaid can also pay some expenses that Medicare doesn’t cover, such as nursing home care and some other long-term care expenses. In some states, Medicaid covers dental care, glasses, physical therapy, transportation to and from doctor visits and other services.
If you don’t qualify for Medicaid, you still may be eligible for some help with Medicare’s out-of-pocket costs from a Medicare Savings Program (MSP), which has higher income cutoffs that also vary by state.
For more information about eligibility and coverage for Medicare, Medicaid and Medicare Savings Programs in your state, contact your State Health Insurance Assistance Program (SHIP).
Updated November 16, 2022
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