What is Medicare?
Medicare is health insurance for adults aged 65 or older and those with certain disabilities. Medicare Part A (hospital inpatient coverage) and Medicare Part B (medical coverage) provide the traditional private fee-for-service coverage, known as Original Medicare, but private health plans are also available.
Many people are surprised to learn that Medicare is not end-to-end healthcare. In fact, from the beginning, Medicare was designed to cover only about 80 percent of a beneficiary’s major medical expenses. All other costs, typically in the form of deductibles, coinsurance, and copays, are the beneficiary’s responsibility. When a beneficiary cannot afford some or all of these costs, due to limited income at or below the federal poverty level, there’s Medicaid.
What is Medicaid?
Medicaid is a federal and state combined program that provides healthcare assistance for low-income families and individuals. Medicaid beneficiaries pay very low copays when receiving care under this program.
While Medicaid is both a state and federal program, it is administered at the state level and each state has its own rules and benefits. All Medicaid programs must follow the same federal guidelines while being directed and managed at the local state level.
What do I need to qualify for Medicaid?
Medicaid eligibility is primarily based on state income guidelines. Each state has different income limits and they administer their plans differently. To qualify, you’ll need your social security number and those of your children (if applicable). You’ll also need proof of income and whether or not you receive other government assistance such as WIC or Food Stamps. You’ll also want documentation of any disability you or your children may have.
You can apply for Medicaid either online through the Health Insurance Marketplace or through your state’s Medicaid agency. Medicaid also includes the CHIP program which is the program for children in low-income households. Even if you don’t qualify based solely on income, certain disabilities, pregnancy, and the elderly may still qualify for aid.
What do I need to qualify for Medicare?
Medicare coverage is for adults 65 and older and those with certain qualifying medical conditions or disabilities. To qualify, you would need proof of age, proof of income (to determine how much your deductible is), residency or citizenship documentation, and more. Since Medicare is a government insurance program, anyone aged 65 or older can apply and receive insurance through this program.
Medicare premiums are based on your income and your work history. The eligibility requirements for Medicare Part A (hospital coverage) are very simple. If you or your spouse worked and paid Social Security taxes for ten or more years, your Medicare Part A premium is free. If not, you will pay a monthly premium for Part A.
With Part B, all Medicare beneficiaries pay a monthly Part B premium, however, if you are a high-income earner you will pay a little more. You can find the current schedule on this Medicare.gov page.
What are the main differences between Medicare and Medicaid?
Medicare is administered at the federal level and is a health insurance program. Medicaid is regulated by the federal government and administered at the state level.
Medicare has premiums, deductibles, copays, and more. Medicaid assists with these costs, but you may be required to use an approved Medicaid health plan. The benefit is the plan will have very low copays and very few additional fees.
Medicare is for those aged 65 and older or those with disabilities or specific medical conditions. Medicaid is for people of any age, with or without medical conditions, so long as they meet the state’s economic conditions.
Medicare is not income-restricted. Medicaid has income limitations and is intended for those with low-income.
Can I have both at the same time?
If you qualify for both Medicare and Medicaid, you can have them both simultaneously. When you have both it means that you are unlikely to have any out-of-pocket medical expenses. Around 20 percent of Medicare beneficiaries are also eligible for Medicaid. They are called dual-eligible. You would need to apply for each one separately to determine if you can qualify for both.
Dual-eligibles are categorized based on whether they receive full or partial Medicaid benefits. Full benefit dual-eligibles receive comprehensive Medicaid coverage, while partial benefit dual-eligibles receive help with their Medicare premiums and cost-sharing through one of four Medicare Savings Programs.
Can I Have A Medicare Advantage Plan with Medicaid?
In a growing number of counties, there are Medicare Advantage plans (Part C) specifically designed for by private insurance companies for Medicare beneficiaries who also qualify for Medicaid. They are called Medicare Advantage Special Needs Plans, or just SNP for short. These unique plans take into account the special needs of low-income seniors in the region they serve and do not have the same cost-sharing requirements (i.e., copays) as normal Medicare Advantage plans.
Some smaller, rural counties may not have SNP plans but will have a local Medicaid plan. You will need to call your local Medicaid office to learn more. Typically Medicaid coverage offers many more benefits than Original Medicare alone.
Can I have a Medicare Supplement and Still Get Medicaid?
Medicare supplement insurance companies cannot sell you a Medigap policy if you are receiving assistance through your state Medicaid program.
Can I Get Help with My Prescription Drugs?
For many people, prescriptions are their number one health care cost. There are several ways that low-income people with both Medicare and Medicaid benefits can get extra help with their prescriptions. The first and most important way is to apply for the Social Security Administration’s Extra Help program. This program provides low-income subsidies (LIS) to those who need them. These subsidies can help you pay all or part of the monthly premium for a Medicare Part D plan, and is worth about $5,000 per year. You will need to call Social Security directly at 1-800-772-1213 to check your eligibility.
If you are able to enroll in a Special Needs Plan, your SNP will include prescription drug coverage and pay many of the out-of-pocket costs with regular Medicare Advantage plans. Enrollees pay small copayments, but you don’t have an annual deductible. You can use our SNP directory to discover enrollment opportunities in your area.
What if I need to be in a Nursing Home?
Medicare covers most of the costs associated with skilled nursing after an inpatient stays in the hospital. If you have both Medicare and Medicaid, a stay at a skilled nursing facility will cost very little.
After inpatient treatment, many patients need more outpatient care in the home setting. To learn how to get financial assistance for home health care, read How to Qualify for Home Health Care & Get Financial Assistance.
If you require assisted living because you are no longer able to live independently, read Does Medicare Cover Assisted Living Costs? What About Independent Living?
If you need long-term care and have limited resources, Medicaid can help, however, strict asset limits do apply. We have a complete guide to long-term care if you need it.
What is the Medicare Savings Program (MSP)?
There are four types of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program
- Specified Low-Income Medicare Beneficiary (SLMB) Program
- Qualifying Individual (QI) Program
- Qualified Disabled and Working Individuals (QDWI) Program
If you answer yes to these 3 questions, call your State Medicaid Program to see if you qualify for assistance in your state:
- Do you have, or are you eligible for, Medicare Part A?
- Is your income at, or below, the federal poverty standard?
- Do you have limited financial resources (approximately $7,500 for individuals or $11,500 for couples)?
If you qualify for the QMB program, SLMB, or QI program, you automatically qualify to get Extra Help paying for Medicare drug coverage.
Citations & References:
- Contact Your State With Questions | Medicaid
- Medicaid.gov: the official U.S. government site for Medicare | Medicaid
- Medicaid.gov: the official U.S. government site for Medicare | Medicaid
- Medicare.gov: the official U.S. government site for Medicare | Medicare
- Medicare Savings Programs | Medicare
- SNF Care Coverage
- Disability Benefits | SSA
- Substantial Gainful Activity
- Social Security Online – Medicare Information