It’s easy to confuse Medicare and Medicaid because they have similar names and are both government programs that pay for health care. But there are essential differences between the programs. For example, Medicare is generally for older people, while Medicaid is for people with limited income and resources.
What Is Medicare?
Medicare is a fee-for-service federal health insurance program that provides reasonably priced health insurance for retired individuals, regardless of their medical condition, and for specific disabled individuals, regardless of age. Centers for Medicare & Medicaid Services manages the benefit.
What Is Medicaid?
Medicaid is a health insurance assistance program jointly administered by state and federal governments. Medicaid serves financially needy individuals who are also elderly, disabled, blind or parents of minor children.
Who Is Eligible for Medicare?
You are eligible for premium-free Part A (hospital insurance) if you are age 65 or older and you (or your spouse) worked and paid Medicare taxes for at least ten years.
You may be able to buy Part A if:
- Neither you (nor your spouse) paid Medicare taxes while you worked
- You are age 65 or older and a citizen or permanent resident of the United States
Medicare coverage also may be available for disabled individuals and people with end-stage renal disease. While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement benefit.
Who Is Eligible for Medicaid?
Each state has different rules about eligibility and applying for Medicaid. To qualify, you must be a resident of the state you are applying to and a U.S. citizen (or have qualified immigration status). While eligibility varies by state, federal law requires states to cover certain groups of individuals. Low-income families, eligible pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. In addition, recipients must meet a financial eligibility requirement. As determined by income and asset limitation tests, the individual must be financially needy.
What Does Medicare Cover?
Currently, Medicare consists of four parts: Original Medicare Part A helps cover costs related to inpatient care in a hospital, a skilled nursing facility, hospice care, and home health care. Original Medicare Part B helps protect services from doctors and other healthcare providers, outpatient care, ambulance services, lab tests, physical therapy, durable medical equipment (like wheelchairs, walkers, hospital beds), and many preventive services such as screenings and vaccines. Medicare Advantage (Part C) replaces Parts A and B and enables beneficiaries to receive health care through managed care plans such as health maintenance organizations and preferred provider organizations. Finally, Medicare Part D helps cover the costs of prescription drugs.
What Does Medicaid Cover?
Each state administers its own Medicaid program within broad federal guidelines. Thus, states determine the amount, duration, and types of Medicaid’s benefits. Typical Medicaid programs cover inpatient and outpatient hospital services; physician and surgical services; lab tests and X-rays; family planning services and preventive care, including immunizations, mammograms, colonoscopies, and other needed care; mental health care; and services for pregnant women. There are also numerous optional benefits that states may offer.
Can Both Medicare and Medicaid cover you?
Some people who qualify for both Medicare and Medicaid are called “dual-eligibles.” Most healthcare costs are likely covered if you have Medicare and full Medicaid coverage.
What About Long-Term Care?
Most long-term care isn’t medical care but instead helps with basic personal tasks of everyday life, called custodial care. Medicare does not pay for custodial care. However, Medicare may pay for skilled care (e.g., nursing, physical therapy) provided in a Medicare-certified skilled nursing facility for up to 100 days. States have considerable leeway in determining benefits offered and services provided by their respective Medicaid programs. Generally, if you meet your state’s eligibility requirements, Medicaid will cover nursing home services, home, and community-based services, and personal care services.
This material has been provided for general informational purposes only and does not constitute either tax or legal advice. Although we go to great lengths to ensure our information is accurate and useful, we recommend you consult a tax preparer, professional tax advisor, or lawyer.
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