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Medicare vs Medicaid: Which One Do I Qualify For?medicare vs medicaid sign


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The U.S. government provides health insurance assistance for millions of Americans. Two of the most-utilized and most-recognized services are Medicare and Medicaid. Some people think these programs are the same thing. They most-certainly are not.

Depending on your needs, you might qualify for either Medicare or Medicaid, or both. Let Senior Market Agents Network help you determine the right coverage for you.

Differences between Medicare and Medicaid

Medicare and Medicaid are insurance programs supported by the federal government and the states. They started in the 1960s to make health care affordable to seniors and those with low incomes.

  • Medicare helps individuals over the age of 65 get health insurance, even after retirement. It can also extend coverage to those with disabilities or chronic illnesses.
  • Medicaid is health insurance coverage for those with very low incomes. States and the federal government manage the program between them. You must meet certain income benchmarks to qualify for Medicaid.

While Medicare and Medicaid are both government programs, they both serve different purposes. Get in touch with one of our our agents to determine your eligibility for each program.

How does Medicare work?

Medicare developed out of the idea that American senior citizens might not have access to affordable health insurance after they retire. Other people with certain disabilities or illnesses might not be able to get covered either. Medicare seeks to fill in that gap. When you enroll, the program can help you receive health insurance coverage for both medically-necessary care and certain elective treatments.

After you sign up for Medicare, you’ll receive an insurance card in the mail. You can then present your card as proof of insurance when you visit the doctor. If your doctor participates in the Medicare program, you can use your coverage. After your plan pays, you will likely pay very little out of pocket for your health care services.

What does Medicare cover?

Medicare is not a single insurance policy. It has multiple plan options. Depending on certain factors, you might qualify for one or more of these policies.

Original Medicare: This was the first Medicare coverage. It consists of Medicare Part A and Medicare Part B coverage. The original Medicare program is supported by the federal Medicare tax.

  • Part A coverage pays for hospital services. Generally, it will cover surgeries, inpatient stays, IV drug treatments and other costs related to a hospitalization.
  • Part B coverage insures medical costs not related to hospitalizations. For example, this coverage might pay for physician visits, vaccinations, lab tests, x-rays and other outpatient costs.

Medicare Advantage Plans: Medicare Advantage plans, also knowns as Medicare Part C, are private health insurance policies. They offer an alternative to Original Medicare. They will include all the coverage offered by Parts A & B coverage, except for hospice care coverage. However, they will also include coverage for services not covered by Original Medicare.

Extra insured costs might include:

  • Prescription drug coverage
  • Dental insurance
  • Hearing services
  • Vision care

Advantage plans come in a variety of shapes and sizes. They might cover different physician networks and have different out-of-pocket costs. However, you will still receive at least the same benefits provided by Original Medicare.

Medicare Prescription Drug Insurance:  Original Medicare (Parts A & B) does not include coverage for most standard prescription drugs. While certain inpatient drugs during hospitalizations often have coverage, those you get from your everyday pharmacy usually don’t. To cover these costs, Original coverage participants have the option to choose Medicare Part D Prescription Coverage.

Part D plans are private policies that you obtain from a major insurer. Plans will generally cover both generic and name-brand medications, while you will pay only a few dollars out-of-pocket. Different plans, however, might cover different drugs. Talk to your provider to determine which policy is best.

Medigap Insurance: Also known as Medicare supplements, Medigap plans are private policies that cover certain out-of-pocket costs you would ordinarily pay if you only have Original Medicare. Covered costs might include:

  • Copayments
  • Deductibles
  • Coinsurance

Plans might also cover certain services not covered by Original Medicare. For example, if you travel outside the U.S. for medical care, your plan might pay some of the costs.

Who qualifies for Medicare?

Most people qualify for Original Medicare (Parts A & B) if they:

  • Are age 65 or older
  • Have a disability. For example, those with Multiple Sclerosis (MS) often qualify. Multiple disabilities and chronic illnesses qualify as Medicare disabilities.
  • Have end-stage renal disease (ESRD). Those who have kidney failure, are on dialysis or have had kidney transplants often qualify for this coverage.

Medicare Advantage enrollees qualify if:

  • You are over 65 years old
  • You have Original Medicare Parts A & B. You must already have Original Parts A & B to qualify for an Advantage plan.
  • You do not have end-stage renal disease (ESRD)

    *
    If you are under 65 and collecting Social Security disability
  • You live in the plan’s service area.

Part D applicants qualify if:

  • You have Medicare Parts A & B insurance.
  • You live within the service area of the Part D plan.
  • You cannot have an existing Medicare Advantage plan.

Medigap plans require applicants to meet any the following qualifications:

  • You are over 65 years old
  • You have end-stage renal disease
  • You receive disability benefits from the Social Security Administration or the Railroad Retirement Board
  • You have ALS (Lou Gehrig’s disease)

How does Medicaid work?

Medicaid is an entirely different type of insurance than Medicare. They exist separately, and applicants must enroll in them separately.

Medicaid will insure low-income families and individuals. Beneficiaries can use Medicaid health plans in the same way they use any other health insurance. You will visit a doctor who accepts you plan and present your card to the physician. The physician will then bill your care to the Medicaid program.

States have the option to charge premiums, deductibles, coinsurance and other cost-sharing bills to Medicaid participants. However, many individual applicants can obtain exemptions for cost-sharing. Those who do not have to share costs include:

  • Pregnant women and infants with family income at or above 150% the Federal Poverty Level (FPL) ($34668 for a family of 2 in 2019)
  • Qualified disabled and working individuals with income above 150% FPL ($17244 for an individual in 2019)
  • Disabled working individuals eligible under the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA)
  • Disabled children eligible under the Family Opportunity Act (FOA)
  • Medically-needy individuals
  • Those seeking preventive care for their children
  • Those who obtain services through an emergency department. However, people who use emergency rooms for non-emergency care will not have an exemption

To learn more about your state’s cost requirements, contact your state’s Medicaid program.

What does Medicaid cover?

States largely manage their Medicaid systems under the oversight of the federal government. Federal law mandates that Medicaid cover at least the following services*:

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: 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 Family 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

Beyond those requirements, states usually require their Medicaid coverage to insure other care, such as:

  • Prescription Drugs
  • Clinic services
  • Physical therapy
  • Occupational therapy
  • Speech, hearing and language disorder services
  • Respiratory care services
  • Other diagnostic, screening, preventive and rehabilitative services
  • Podiatry services
  • Optometry services
  • Dental Services
  • Dentures
  • Prosthetics
  • Eyeglasses
  • Chiropractic services
  • Private duty nursing services
  • Personal Care
  • Hospice
  • Case management

Contact your state’s Medicaid program to learn more about coverage options.

*Source: https://www.medicaid.gov/medicaid/benefits/list-of-benefits/index.html

Who qualifies for Medicaid?

Your Medicaid qualifications will depend on several factors. These might include:

  • Your annual income
  • Whether you have children
  • Your marital status
  • If you have disabilities
  • Whether you are caring for children with disabilities

However, each state has the right to determine Medicaid eligibility within their own borders. To determine your eligibility, look at your state’s requirements. Federal law makes certain groups, such as pregnant women in poverty, automatically eligible.

Do I need Medicaid if I have Medicare?

You don’t have to carry Medicaid if you already have Medicare. However, many individuals qualify for both Medicare and Medicaid at the same time. This is called a dual-eligibility situation. You will need to meet all the eligibility requirements of both programs to enroll in each.

If you have both Medicare and Medicaid, your Medicare will pay for its portion of the services covered by your plan. Then the Medicaid can step in to cover most or all remaining costs of care. Furthermore, your Medicaid might cover services not insured under traditional Medicare.

You can also use Medicaid along with other health insurance plans. However, please note that Medicaid is a payer of last resort. Medicaid will only step in pay benefits after your original coverage has paid first.

Here at Senior Market Agents Network, we understand all eligibility requirements for those interested in the Medicare program. Contact us at 877-209-4949 or request policy assistance online today.

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Senior Market Agents Network is not connected with or endorsed by the United States government or the federal Medicare program. Senior Market Agents Network is an Independent Insurance Agency Licensed in New Jersey, New York, Pennsylvania, Maryland, Virginia, West Virginia, South Carolina, North Carolina, Georgia, Florida, Ohio, Texas, Arizona and Michigan.