Medicare and Medicaid

Medicare and Medicaid are two separate programs that are both run by the government. A person may qualify to receive benefits from one or both programs. The major difference between Medicare and Medicaid is that Medicare covers health care mainly for people age 65 and older. Medicaid is for people with low income.

  • Medicare provides health coverage for individuals ages 65 and older. Some individuals younger than 65 may also receive Medicare benefits if they have certain disabilities or diseases. A person with kidney failure requiring dialysis or a transplant is one example of someone that would qualify. Medicare is federally funded, and enrollment is not based on income.
  • Medicaid is a state and federal program that provides health coverage.  Medicaid is focused on helping individuals with lower income. Limited assets and income are the major factors in determining if a person qualifies.  Each state has its own requirements for how much money a person/family can make and be eligible for Medicaid.

Medicare and Medicaid (Dually Eligible)

Some individuals qualify for both Medicare and Medicaid coverage. A person that is eligible for both programs is referred to as being Dual Eligible or having Dual Eligibility. Both Medicare and Medicaid work together and limit out of pocket costs for healthcare.

All states have Medicaid programs and coverage will vary by state. If you are enrolled in Medicare and have limited income/resources, you may get help paying your premiums and out-of-pocket medical expenses from Medicaid.

Examples of Medicare and Medicaid working together.

  • Medicaid can provide secondary insurance: For covered services Medicare is the primary insurance. Medicaid would be considered secondary and would pay last. When you visit a provider or facility that takes both forms of insurance, Medicare will pay first and then Medicaid would possibly cover costs such as coinsurances and copays.
  • Medicaid can provide help for premiums:  If you have Medicare and Medicaid, your Medicare Part B premiums would more than likely be covered and paid for by Medicaid.
  • Medicaid and Medicare Part D (prescriptions): Dual eligible individuals are automatically enrolled in the Extra Help Program. This program helps with cost of the Part D plan and limits out of pocket costs for prescriptions.

Special Needs Plans

There are health plans that a Dual Eligible Person may qualify for that are called Dual Eligible Special Needs Plans (D-SNPs).  Only individuals with both Medicare and Medicaid may enroll. These D-SNP plans combine services and benefits into one healthcare plan. Special needs plans will also provide additional benefits and resources to assist with healthcare for the individual.

Summary

  • Medicare covers mostly people age 65 and older, whereas Medicaid covers individuals with limited income.
  • Medicaid is usually free. Medicare has premiums, copays, coinsurance and deductibles.
  • Medicaid will cover some benefits Medicare doesn’t. Examples include nursing home and personal care services.
  • Medicare and Medicaid work together to pay for your health care.