Medicare and Medicaid are U.S. government-sponsored programs designed to help cover healthcare costs for American citizens. Established in 1965 and funded by taxpayers, these two programs have similar-sounding names, which can trigger confusion about how they work and the coverage they provide.
Medicare provides medical coverage for many people age 65 and older and those with a disability. Eligibility for Medicare has nothing to do with income level. Medicaid is designed for people with limited income and is often a program of last resort for those without access to other resources.
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Medicare vs. Medicaid: An Overview
- Medicare is the primary medical coverage provider for seniors and those with a disability.
- Medicaid is designed for people with limited income.
- Medicare has four parts that each cover different things—hospitalization, medically necessary services, supplemental coverage, and prescription drugs.
Medicare helps provide healthcare coverage to U.S. citizens who are 65 years of age or older, as well as people with certain disabilities. The four-part program includes:
Medicare Part A provides hospitalization coverage to individuals who are 65 years or older, regardless of income. To qualify, you or your spouse must have worked and paid Medicare taxes for at least 10 years. Most people don't pay a premium for Part A, but deductibles and coinsurance apply.
Those eligible for Medicare Part A also qualify for Part B, which covers medically necessary services and equipment. This includes doctor’s office visits, lab work, x-rays, wheelchairs, walkers, and outpatient surgeries, as well as preventive services such as disease screenings and flu shots.
For 2021, the standard Part B premium is $148.50 (generally deducted from Social Security or Railroad Retirement payments). Deductibles and coinsurance apply. Individuals who earn more than $88,000 per year ($176,000 for a couple) are obligated to pay more for this program.
Individuals are not mandated to sign up for Part B as soon they are eligible if they are still covered by their employer’s insurance. However, it may cost more to join later in life, due to a late-enrollment penalty.
Individuals who are eligible for Medicare Part A and Part B are likewise eligible for Part C, also known as Medicare Advantage. Medicare Part C plans are offered by private companies approved by Medicare.
In addition to providing coverage offered by Parts A and B, Part C offers vision, hearing, and dental coverage, and may also provide prescription drug coverage. In that way, it functions much like the health maintenance organizations (HMOs) and preferred provider organizations (PPOs), through which many people receive medical services during their working years.
Enrolling in Part C may reduce the costs of purchasing services separately. Individuals should carefully evaluate their medical needs because Part C participants generally pay out-of-pocket for the associated services.
Medicare Supplement Insurance, known as Medigap, may be purchased to help cover expenses such as copayments, coinsurance, and deductibles that are not covered by Parts A and Part B. However, physicians who do not take Medicare also do not accept Medigap.
Medicare Part D provides prescription drug coverage. Participants pay for Part D plans out-of-pocket, and must pay monthly premiums, a yearly deductible, and copayments for certain prescriptions. Those enrolled in Medicare Part C will only want to consider Part D if their plan has no prescription drug coverage.
The annual Medicare open enrollment period runs from Oct. 15 to Dec. 7 for 2021.
|2021 Medicare Costs at a Glance|
|Part A premium||Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $471 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $471. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $259.|
Part A hospital inpatient deductible and coinsurance
- $1,484 deductible for each benefit period
- Days 1-60: $0 coinsurance for each benefit period
- Days 61-90: $371 coinsurance per day of each benefit period
- Days 91 and beyond: $742 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
- Beyond lifetime reserve days: all costs
Part B premium
The standard Part B premium amount is $148.50 (or higher depending on your income).
Part B deductible and coinsurance
$203 per year. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy and durable medical equipment (DME).
Part C premium
The Part C monthly premium varies by plan.
Compare costs for specific Part C plans
Part D premium
The Part D monthly premium varies by plan (higher-income consumers may pay more).
Compare costs for specific Part D plans
Medicaid is a joint federal and state program that helps low-income Americans of all ages pay for the costs associated with medical and long-term custodial care. Children who need low-cost care but whose families earn too much to qualify for Medicaid, are covered through the Children's Health Insurance Program (CHIP), which has its own set of rules and requirements.
Medicaid Eligibility and Costs
The federal/state partnership results in different Medicaid programs for each state. Through the Affordable Care Act (ACA), which was signed into law in 2010, President Barack Obama attempted to expand healthcare coverage to more Americans. As a result, all legal residents and citizens of the United States with incomes of up to 138% of the poverty line qualify for coverage in Medicaid participating states.
While the ACA has worked to expand both federal funding and eligibility for Medicaid, the U.S. Supreme Court ruled that states are not required to participate in the expansion in order to continue receiving already established levels of Medicaid funding. Many states have chosen not to expand funding levels and eligibility requirements.
Those covered by Medicaid pay nothing for covered services. Unlike Medicare, which is available to nearly every American of 65 years and over, Medicaid has strict eligibility requirements that vary by state.
However, because the program is designed to help the poor, many states require Medicaid recipients to have no more than a few thousand dollars in liquid assets in order to participate. There are also income restrictions. For a state-by-state breakdown of eligibility requirements, visit Medicaid.gov and BenefitsCheckUp.org.
When Medicaid recipients reach age 65, they remain eligible for Medicaid and also become eligible for Medicare. At that time, Medicaid coverage may change, based on the recipient's income. Higher-income individuals may find that Medicaid pays their Medicare Part B premiums. Lower-income individuals may continue to receive full benefits.
Medicaid benefits vary by state, but the Federal government mandates coverage for a variety of services, including:
- Laboratory services
- Doctor services
- Family planning
- Nursing services
- Nursing facility services
- Home healthcare for people eligible for nursing facility services
- Clinic treatment
- Pediatric and family nurse practitioner services
- Midwife services
Each state also has the option of including additional benefits, such as prescription drug coverage, optometrist services, eyeglasses, medical transportation, physical therapy, prosthetic devices, and dental services.
Medicaid is also often used to fund long-term care, which is not covered by Medicare or by most private health insurance policies. In fact, Medicaid is the nation's largest single source of long-term care funding, which often covers the cost of nursing facilities for those who deplete their savings to pay for healthcare and have no other means to pay for nursing care.
What's the difference between Medicaid and Medicare?
Medicare is available to individuals based on age or disability. If your eligibility depends on age, you'll have access to the program once you turn 65. Medicaid is designed for individuals in low-income situations, or other special circumstances.
How can I get Medicaid?
Not everyone qualifies for Medicaid. If your income falls below the poverty level, determined by your state, you might qualify. There are also a number of mandatory eligibility groups, including some pregnant women and children and individuals receiving Supplemental Security Income.
What is the CARES Act?
The CARES Act expands coverage, and was signed into law by President Trump on March 27, 2020. This $2 trillion stimulus package ensures that Medicare coverage expands to cover Americans impacted by COVID-19. It increases healthcare flexibility, like covering more telehealth services. The CARES Act allows Medicaid programs in non-expansion states to cover uninsured individuals' COVID-19 needs.