How to Qualify for
Medicare & Medicaid
This page provides an overview of information and topics related to Medicare and Medicaid. We also provide in-depth articles on most of these topics, which will provide more specific details and actionable information. Just click through the links if you have questions about any of the programs or plans covered on this page.
Both Medicare and Medicaid are important programs for the health and well-being of Americans. They work both individually and collaboratively, supported by federal and state resources. Many people may qualify for both Medicare and Medicaid. Confusing the two programs is easy, but we’re here to ensure you have the resources you need to make the most of both Medicare and Medicaid.
Medicare Basics
Medicare is a federal program providing health insurance for those 65 and older or at any age with Social Security disability benefits.
Medicare is made up of two main segments, often referred to as Original Medicare: Part A (hospital coverage) and Part B (medical coverage). Medicare beneficiaries can also supplement their coverage with a Part C, Part D, or Medigap plan to assist with Medicare costs.
Once you are eligible for Medicare based on age (65 or older), you are eligible forever.
Medicaid Basics
Medicaid is a program providing healthcare and health savings for low-income individuals and families. Medicaid is governed by a federal set of guidelines and agreements, but is individually managed by each state. Eligibility for Medicaid is generally based on income and resources, but the exact qualifications vary by state.
Because Medicaid eligibility is determined by income, you can become eligible or ineligible a number of times over the years.
How to Qualify for Both Medicare and Medicaid
Because Medicaid eligibility varies by state, it’s best to check with your state health program to confirm that you qualify for both Medicare and Medicaid. You may qualify for both Medicare and Medicaid if you:
- Are 65 or older
- Are younger than 65 and receive Social Security disability benefits
- Have a limited income
How Medicare & Medicaid Work Together
Several Medicaid programs assist low-income individuals or couples with paying Medicare costs, such as premiums, deductibles, copayments, and prescription drug costs.
If you qualify for both Medicare and Medicaid, you are considered dual-eligible. Dual-eligible individuals usually have more opportunities to change their Medicare coverage throughout the year than beneficiaries who just have Medicare.
Medicare and Medicaid are both overseen by a federal agency called the Centers for Medicare & Medicaid Services (CMS).
Medicare Savings Programs
Medicare Savings Programs are Medicaid-funded initiatives to help dual-eligible individuals pay for Medicare costs. There are four Medicare Savings Programs:
Qualified Medicare Beneficiary (QMB) Program: Covers Medicare Part A and B premiums, deductibles, copayments, and coinsurance.
Specified Low-Income Medicare Beneficiary (SLMB) Program: Pays Medicare Part B premiums.
Qualifying Individual (QI) Program: Pays Medicare Part B premiums. These benefits must be applied for every year and they’re awarded on a first-come first-serve basis. Medicaid recipients are not eligible for this program.
Qualified Disabled and Working Individuals (QDWI) Program: Helps pay Medicare Part A premiums and is available if you were previously receiving Medicare coverage with your disability benefits but have now returned to work and lost your disability coverage.
You can contact your state Medicaid office to discuss eligibility or apply for a Medicare Savings Program.
Extra Help or Low-Income Subsidy
Extra Help is the program that helps cover your costs related to prescription drug coverage. Most dual-eligible individuals are qualified for Extra Help. Some individuals who are not eligible for Medicaid but have low income and resources may be eligible for partial Extra Help assistance. Extra Help may pay your prescription drug premium and deductible, as well as set a maximum cost to your prescription drugs.
Dual-Eligible Special Needs Plans
Dual-Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan offered by private insurance companies specifically for individuals who qualify for both Medicare and Medicaid. They include all the same benefits as Medicare Parts A and B, with the convenience of a plan that’s designed to work with both programs. Many of these plans may offer additional benefits as well and may have $0 premiums, deductibles, or copayments.
All Medicare plans offered by private insurance companies are monitored and closely regulated by the Centers for Medicare and Medicaid Services to ensure they’re offering the benefits and pricing required by each program. CMS also issues plan ratings based on customer satisfaction with each plan, measured in multiple ways. Every year, Medicare evaluates plans based on a 5-star rating system. These ratings are on a 5-star scale, with 5 stars being the highest rating.
Enrollment Eligibility
Annual Enrollment Period (AEP)
Medicare Annual Enrollment Period runs each year from October 15 to December 7. What is the Annual Enrollment Period vs. Open Enrollment Period?
Initial Enrollment Period (IEP)
Your Initial Enrollment Period generally surrounds your 65th birthday but may occur if you otherwise become eligible for Medicare for the first time.
Special Enrollment Period (SEP)
You may be eligible if you experience a qualifying life event such as moving to a new zip code, losing employer coverage, or change in Medicaid status.
Further Reading:
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Last Updated: September 30, 2024
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