The United States has two major government-provided health insurance programs: Medicare and Medicaid. It can be easy to confuse these two programs with similar names and perhaps miss out on benefits or assistance you may be qualified to receive. Let’s compare Medicare vs Medicaid.
What is Medicare?
Medicare is a federal health insurance program for people who are:
- 65 years of age or older
- Under 65 years of age with disabilities
- Of any age that have End Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s Disease)
Who Governs Medicare?
The federal government, specifically a department called the Centers for Medicare & Medicaid Services (CMS).
How Much Does Medicare Cost?
It all depends on which plan coverage you choose. Costs may include deductibles, premiums, copays and coinsurance.
In general, you will probably:
- Receive premium-free Part A, only paying a deductible and copays
- Pay a Part B premium, as well as a deductible and copays
- Pay for prescription drug coverage, likely with a premium, deductibles, and copays
There are a number of ways to bundle your coverage, save money, and receive assistance.
What Does Medicare Cover?
Depending on the Medicare coverage you choose, it may include:
- Care and services (inpatient) in a hospital or skilled nursing facility (Part A)
- Doctor visits, care and services (outpatient), and possible preventative care (Part B)
- Prescription Drugs (Part D)
Medicare Advantage (Part C) plans will combine both Medicare Part A and Part B, and often include prescription drug (Part D) coverage as well – all together in one plan. Medicare Advantage Plans generally include additional benefits as well, such as:
Am I Eligible for Medicare?
Once you turn 65 years old, you are most likely eligible for Medicare. To confirm that you are eligible for Medicare, contact your local Social Security office for more information.
If you haven’t paid into Social Security for 40 quarters, you may have higher Medicare costs, but you are still eligible to enroll.
What is Medicaid?
Medicaid is a federal and state program that helps pay healthcare costs for individuals and/or families with low assets and incomes.
Who Governs Medicaid?
The governments of individual states, in collaboration with the Centers for Medicare & Medicaid (CMS), an agency of the federal government.
How Much Does Medicaid Cost?
It all depends on your current income and specific rules of the state that you are living in.
What Does Medicaid Cover?
Each state has different Medicaid programs that follow the federal structure. There are mandatory benefits as well as optional benefits. These are the mandatory benefits:
- Care and services received in hospital or skilled nursing facility
- Care and services received in a federally-qualified health center, birth center or rural health clinics
- Doctor, certified pediatric, nurse, midwife, family nurse practitioner services and more
Am I Eligible for Medicaid?
Each state is different when it comes to eligibility. You can call your local Medicaid office to see if you qualify for coverage.
What’s the Difference Between Medicare and Medicaid?
Medicare is a federal program for people 65 and older or those with Social Security Disability Benefits.
Medicaid is a combined state and federal program with eligibility based on income and resources.
What is Dual Eligibility?
People who qualify for both Medicaid (supports low-income individuals and families) and Medicare Part A/Part B are known as dual eligible. What does this mean? It means that you may qualify for benefits that are run through the state called “Medicare Savings Programs.” These programs provide coverage for certain premiums, copays, and deductibles. The benefits ultimately depend on an individual’s income level and Medicare Savings Program, but sometimes Medicaid can cover all out-of-pocket expenses. Individuals who qualify for the Qualified Medicare Beneficiary (QMB) Program may automatically qualify for the Extra Help Prescription Drug Program.
When dual eligible individuals receive Medicare and Medicaid benefits, some can vary by state.
Dual eligibility can also be categorized as “full-benefit” or “partial-benefit.” Full benefits mean that the individual would receive full coverage of Medicaid benefits. However, those with partial benefits do not receive the full Medicaid services, but Medicaid will cover their Medicare premiums.
Dual Special Needs Plans
If you are enrolled in both Medicare and Medicaid, you’re eligible for a specific type of Medicare Advantage Plan called a Dual-Eligible Special Needs Plan (D-SNP). These plans coordinate the combined benefits of Medicare and Medicaid to help you get the care and resources you need. Some plans may offer $0 premiums and additional benefits.
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.
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