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Medicare vs. Medicaid: How to Tell the Difference

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Medicare vs. Medicaid: How to Tell the Difference

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Updated: December 6, 2018    Published: November 12, 2018

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You know you need government-sponsored insurance to help cover your healthcare costs, but do you need Medicare or Medicaid? And what’s the difference between the two anyway?

If you’re confused, you’re not alone. Medicare and Medicaid are often mentioned together, but their differences are rarely fully explained.

Despite similar names, Medicare and Medicaid play dissimilar purposes and primarily serve different groups. Click To Tweet

Medicare provides health coverage if you are 65 and older or have a severe disability, no matter your income.

Medicaid provides health coverage if you or your family has a very low income.

It’s important to fully understand the differences between Medicare and Medicaid so you can seek out the health insurance that’s right for you.

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At a Glance: Medicare vs. Medicaid Key Differences Chart

Medicare Medicaid
Who runs the program? The Federal Government State and Federal Governments
Who is it for?
  • Seniors ages 65 and older
  • Individuals of any age who receive Social Security Disability Income (SSDI)
  • Individuals of any age with end-stage renal disease
Low- to no- income people who meet their state eligibility standards** including:

  • families and children
  • pregnant women
  • the elderly
  • people with disabilities

**Specific eligibility requirements vary from state to state

What does it cover? Medicare is broken into parts A, B, C, and D, each providing different areas of coverage, which include:

  • Routine and emergency care
  • Preventative services
  • Hospice care
  • Prescription drugs
  • And more

Optional benefits like Medicare Supplement, or Parts C and D help pay your out-of-pocket costs. Your benefits will vary depending on the supplemental coverage you choose.

Medicaid coverage is determined on a state-by-state basis, but each state must include the following benefits:

  • Routine and emergency care
  • Family planning
  • Preventative services
  • Hospice care
  • Substance abuse and smoking cessation programs
  • And more
What services of note are not covered?
  • Long-term nursing home or at-home care
  • Dental and vision
  • Chiropractic services
  • Upcharges at hospitals, optometrists and more
What does it cost? Medicare costs vary depending on the coverage you choose. Costs may include premiums, deductibles, copays, and coinsurance. Medicaid costs depend on your income and the rules in your state. Medicaid may include low out-of-pocket costs.

To help you better understand Medicare vs. Medicaid, let’s look into each program with a little more detail.

Medicare Is for Older Americans:

Medicare is a national health insurance program for many people aged 65 and older. It is also available for people with certain disabilities or end-stage kidney failure. Your eligibility for this program has nothing to do with your income level.

This program is divided into several parts: Medicare Part A and B (Original Medicare) plus optional elements like Medicare Supplement, Medicare Part C and Medicare Part D.

  • Part A provides inpatient/hospital coverage.
  • Part B provides outpatient/medical coverage
  • Part C (also known as Medicare Advantage plans) are Medicare-approved private health insurance plans that replace your Part A and Part B coverage.
  • Part D provides prescription drug coverage.
  • Medicare Supplement plans add on to, but do not replace, your Part A and Part B.

Original Medicare (Part A and Part B):

When enrolling for Medicare, unless you choose otherwise, you will receive Original Medicare, which includes Parts A and B. Under Original Medicare, the government pays directly for the healthcare services you receive. You can see any doctor and hospital that takes Medicare anywhere in the country.

While Medicare Part A and Part B cover a variety of necessary health services, they don’t cover everything. That’s where extra coverage like Medicare Part C and Part D come in.

Extra Medicare Coverage:

Medicare Advantage (Part C): If you’re enrolled in Original Medicare (Part A and Part B), you can choose to replace it with  a private Medicare Advantage plan. They generally offer additional benefits, such as vision, dental, and hearing. Many Part C plans also include prescription drug coverage.

Medicare Supplement (Medigap): Alternatively, you could look into one of the 10 Medicare Supplement plans. These plans pay your Original Medicare out-of-pocket costs – including your 20 percent outpatient copayment and your inpatient hospital deductible. They do not replace your Original Medicare.

Part D Prescription Drug Plans: If you don’t get prescription drug coverage elsewhere you can choose to sign up for a Part D plan. This will help keep the costs of your prescription medications low.

It’s important to note that long-term nursing home or at-home care is not covered under Medicare. If this is an important option for you and you choose Medicare as your health care provider, you may want to consider a separate long-term care insurance policy.

Medicaid is For Lower-Income Americans:

Medicaid is a joint federal-state health insurance program that provides health coverage for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities. Often, Medicaid is chosen by those without the ability to access other healthcare resources.

Since Medicaid is administered on the state level, each state sets their own rules for eligibility and coverage. Depending on which state you live in, you may qualify for Medicaid based on your income, household size, disability, family status, and other factors.

Regardless of which state you live in, the following Medicaid benefits are mandatory under federal law:

  • Inpatient hospital services
  • Outpatient hospital services
  • Early and Periodic Screening, Diagnostic and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse-midwife services
  • Certified pediatric and nurse practitioner services
  • Freestanding birth center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women

Medicaid offers many optional services as well such as prescription drug coverage, physical therapy, and hospice care, but it is up to each state to decide what is included in your coverage.

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Dual Eligibility: What if You Qualify for Both Medicare and Medicaid?

In some cases, you may be eligible for coverage under both Medicare and Medicaid. This is called “dual” or “dual eligible.” The plans specifically available for people with these needs in mind are called Dual Special Needs plans, or DSNPs. These plans often cover benefits not offered by Medicare, such as routine hearing, vision and dental coverage.

To qualify to be dual eligible for both Medicare and Medicaid, you must receive Medicare Parts A and B and full Medicaid benefits. This means Medicaid pays for all or part of your Medicare copayments, coinsurance and deductibles.

Medicare Disability vs. Medicaid Disability:

If you’re disabled, the question of whether Medicare disability or Medicaid disability is right for you may feel even more complicated because there are a few more steps and rules to consider.

Essentially, if you’re disabled and are approved for Social Security disability insurance (SSDI) benefits, you will be eligible to receive Medicare, but not until after you’ve received 24 months of payments. So while your SSDI eventually gives you access to receiving Medicare benefits, it may be two years before that’s a legitimate option for you.

However, if you’re approved for Supplemental Security Income (SSI) you’ll be immediately eligible to receive Medicaid. There is no waiting period for SSI recipients to receive Medicaid. So, once you’re approved for SSI, you can apply for Medicaid in your home state.

Take the Next Step

Medicare and Medicaid target two different groups: older Americans and lower-income Americans. Now that you understand the differences between Medicare and Medicaid a little better, you can move forward with the plan that’s right for you.

Understanding Medicare: If you’re interested in signing up for Medicare, you can enroll in Part A and B online. For extra coverage, you can learn more about Medicare Supplement and Medicare Advantage.

Getting Medicaid: If you’re interested in signing up for Medicaid, use our health insurance search below. It will either alert you if your yearly income qualifies for Medicaid. Or, it will calculate your Obamacare tax subsidy if you’re just over the Medicaid limit.

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