What Are The Differences Between Medicare And Medicaid
Medicare is a federal health insurance program open to Americans age 65 and older and those under the age of 65 with specific disabilities. Medicaid, a combined state and federal program, is a state-specific health insurance program for low-income individuals with limited financial means, regardless of their age.
Medicare, generally speaking, offers the same benefits to all eligible participants. However, coverage is divided into Medicare Part A, Part B, and Part D. Medicare Part A is for hospice care, skilled nursing facility care, and in-patient hospital care. Medicare Part B is for out-patient care, durable medical equipment, and home health care. Part D is for prescription coverage. Not all persons will elect to have coverage in all three areas. In addition, some persons choose to get their Medicare benefits via Medicare Advantage plans, also called Medicare Part C. These plans are available via private insurance companies and include the same benefits as Medicare Part A and Part B, as well as some additional ones, such as dental, vision, and hearing. Many Medicare Advantage plans also include Medicare Part D.
Medicaid is more comprehensive in its coverage, but the benefits are specific to the age group. Children have different eligibility requirements and receive different benefits from low-income adults and from elderly or disabled persons.
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Qualified Disabled And Working Individual
You may be eligible to purchase Medicare Part A benefits, but unable to afford it because of your low income. In this case, Medicaid will pay your Medicare Part A premium. This is more common with people under the age of 65.
In 2021, the maximum monthly income to qualify is $4,379 for an individual and $5,892 for a couple. The 2021 maximum asset level, however, is set at just $4,000 for an individual and $6,000 for a couple.
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Qualified Disabled & Working Individuals
Pays for the Medicare Part A premium if you are working, disabled, and under 65 OR if you lost your premium-free Part A when you went back to work. You must not be receiving state medical assistance. You also:
- Cannot exceed individual monthly income limit of $4,132
- Cannot exceed married monthly income limit of $5,572
- Cannot exceed individual assets limit of $4,000
- Cannot exceed married assets limit of $6,000
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Can I Select An Insurance Plan For My Medicare And Medicaid Benefits
If you are dual eligible, you are can enroll in a dual eligible special needs plan that covers both Medicare and Medicaid benefits. These plans may also pay for expenses that Medicare and Medicaid dont over individually, including over-the-counter items, hearing aids, and vision or dental care.
Beneficiaries who are dual eligible can change between Original Medicare and Medicare Advantage or switch Part D plans at each quarter.
Read more about the Medicaid benefits available to Medicare enrollees.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including at Sachs Policy Group, where he worked with insurer, hospital and technology clients.
Who Qualifies For Medicare Vs Medicaid
Nearly every American will one day qualify for Medicare, but Medicaid is only for those with a low income. Beneficiaries can enroll in Medicaid through the state program office. If you think you are eligible for Medicaid benefits, contact your state health department to apply. To qualify for Medicaid, your income will need to be below a predetermined amount set by your state government.
If your income is above this amount, but you struggle with high medical costs, you may want to check if a Medicaid spend-down program is available in your state. Medicaid spend-down programs allow beneficiaries who exceed the income requirement to deduct their medical costs from their income to meet the state-appointed income requirement.
To qualify for Medicare, you must meet the below requirements:
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Be a U.S. Citizen or documented resident for at least five years AND one of the following:
- Age 65 or above
- Amyotrophic lateral sclerosis diagnosis
- Receiving SSDI benefits for at least 24 months
As you can see, eligibility requirements for the two health insurance programs differ. However, some people fit into the cross-section of qualifications. If you qualify for both, the two health programs work together.
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Reaching Age 62 Can Affect Your Spouse’s Medicare Premiums
Although reaching age 62 does not qualify you for Medicare, it can carry some significance for your spouse if they receive Medicare benefits.
When one spouse in a couple turns 62 years old, the other spouse who is at least 65 years old may now qualify for premium-free Medicare Part A if they havent yet qualified based on their own work history.
- For example, Gerald is 65 years old, but he doesnt qualify for premium-free Part A because he did not work the minimum number of years required for eligibility. He can still receive Medicare Part A, but he will have to pay a monthly premium for it. In 2020, the Medicare Part A premium can be as high as $458 per month.
- Lets say Geralds wife, Jessica, reaches age 62 and has worked for the required number of years to qualify for premium-free Part A once she turns 65. Because Jessica is now 62 years old and has met the working requirement, Gerald may now receive premium-free Part A.
In the above example, Jessica has not become eligible for Medicare by turning 62. Her husband Gerald, however, is now eligible to receive his Medicare Part A benefits without paying a monthly premium any longer.
Q How Do I Join A Managed Care Organization
A. After being notified that you are eligible for Medicaid , you will receive in the mail a packet of information about the different MCO plan options for receiving your Medicaid benefits. You may choose any plan described in this mailing. You probably want to choose a Managed Care Organization to which your doctor belongs. If you need help making this decision, call the Health Benefit Manager at the phone number in the mailing.
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Does Medicaid Pay Secondary To Medicare Advantage Plans
Medicaid is always the secondary payer when it comes to health insurance, says Watts.
Medicaid never pays first for services covered by Medicare. Instead, it pays for whatever isnt covered by Medicare. Medicaid may also cover some drugs and additional services that the Medicare Advantage plan doesnt cover fully or at all.
Medicaid is a great benefit for consumers who are eligible, says Watts. However, if you dont meet the criteria, he recommends looking into other avenues of help that may be available. For instance, if you dont qualify for Medicaid, you may qualify for a Low Income Subsidy . LIS helps cover prescription card costs, and pays for a portion of your drugs as well, says Watts.
Some states like New York may have pharmacy assistance programs, as well as additional help from private drug companies.
Does Medicaid Qmb Cover Medicare Advantage Plans
The terminology around QMB and Medicare/Medicaid can get confusing and can vary by state, says Watts. A QMB is a Qualified Medicare Beneficiary program, which means that Medicare premiums and coinsurance and copayment for Medicare-covered services are covered by Medicaid.
A QMB Plus program is when someone gets full Medicaid benefits.
Either way, these QMB programs do work with both Original Medicare and Medicare Advantage plans. Because these plans can be confusing, its a wise idea to consult with someone or connect with a plan provider who can clearly explain your options.
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How To Apply For Medicaid
If youâre eligible for Medicaid, you can apply all year round through your states Medicaid website or HealthCare.gov, the federal health insurance marketplace. If you apply for Medicaid through Healthcare.gov and it looks like you qualify, the federal government will notify your state agency, which will contact you about enrollment. States also generally let you print out paper applications you can mail, fax or return directly to your local government office.
To complete your Medicaid application, you will likely need to provide documentation that you meet your states requirements. This documentation may include:
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Your birth certificate or drivers license to serve as proof of age and citizenship
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Recent pay stubs or tax returns to serve as proof of income
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Copies of bank statements
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Proof of address, which could include a lease, utility bill statements or a copy of your mortgage
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Medical records to serve as proof of disability
States have 45 days to process your Medicaid application. They have 90 days if eligibility is tied to a disability . Processing can take longer if applicants do not supply all of the required documentation. If you dont qualify for Medicaid, you might be able to get subsidized health insurance through Healthcare.gov. However, only certain life events allow you to apply for a marketplace health care plan outside of open enrollment, which takes place from Nov. 1 to Jan. 15.
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Can I Decline Medicare Altogether
Medicare isnt exactly mandatory, but it can be complicated to decline. Late enrollment comes with penalties, and some parts of the program are optional to add, like Medicare parts C and D. Medicare parts A and B are the foundation of Medicare, though, and to decline these comes with consequences.
The Social Security Administration oversees the Medicare program and recommends signing up for Medicare when you are initially eligible, even if you dont plan to retire or use your benefits right away. The exception is when you are still participating in an employer-based health plan, in which case you can sign up for Medicare late, usually without penalty.
While you can decline Medicare altogether, Part A at the very least is premium-free for most people, and wont cost you anything if you elect not to use it. Declining your Medicare Part A and Part B benefits completely is possible, but you are required to withdraw from all of your monthly benefits to do so. This means you can no longer receive Social Security or RRB benefits and must repay anything you have already received when you withdraw from the program.
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How Mepd Services Are Provided
If youre an adult with a disability and qualify for MEPD, these services are typically provided by STAR+PLUS. You will choose a STAR+PLUS health plan from the ones available in your service area.
If you have a child with a disability who qualifies for MEPD, these services are typically provided by STAR Kids. You will choose a STAR Kids health plan from the ones available in your service area.
You might also be enrolled into traditional Medicaid. Traditional Medicaid just means the state pays your doctors, nurses and other caregivers directly.
Where Can I Find Out More
- Medicaid.gov has links to information explaining the program and to every states Medicaid office.
- Each state has a State Health Insurance Assistance Program that provides counseling and help for Medicare beneficiaries. SHIP counselors can answer some of your Medicaid questions and refer you to local Medicaid officials to help with others.
- The National Council on Aging has a benefits checkup website that has information on Medicare, Medicaid and other programs that help older Americans.
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Get Important News & Updates
Sign up for email and/or text notices of Medicaid and other FSSA news, reminders, and other important information. When registering your email, check the category on the drop-down list to receive notices of Medicaid updates check other areas of interest on the drop-down list to receive notices for other types of FSSA updates.
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Opting For Part A Only
Some people choose only to have Medicare Part A coverage so that they dont have to pay the monthly premiums for Medicare Parts B and D. If you still have insurance through a current employer , you can add the other parts later with no penalty.
However, if you decline Parts B and D and don’t have another insurance plan in place, you’ll face a late enrollment penalty when you add the other parts later.
In the past, Medicaid programs typically didn’t offer a lot of choice in terms of plan design. Today, most states utilize Medicaid managed care organizations . If there’s more than one MCO option in your area of the state, you will likely be given the option to select the one you prefer.
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Who Qualifies For Medicaid
Medicaid qualification is different in every state. You must be a resident of the state in which you are applying for benefits and must be a U.S. citizen or otherwise qualified non-citizen such as a lawful permanent resident.
Federal law requires every state to provide Medicaid to the following mandatory eligibility groups that meet certain income and asset requirements:
As you can see from the federal guidelines, the only reference to age is in regards to children. Each state governs its own Medicare program in adherence to federal regulations. Some states may have an age requirement in order to qualify for its Medicaid program while other states may not.
You can find your states Medicaid eligibility requirements to learn more.
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Medicare is a comprehensive health care plan, but one that Americans must pay for via deductibles and premiums. Those who have low income may be eligible for Medicaid in addition to Medicare. This is known as dual eligibility and means those who are unable to pay Medicare-related expenses can still access the medical services they need.
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Medicare And Medicaid: How To Qualify For Both
Home / FAQs / General Medicare / Medicare and Medicaid: How to Qualify for Both
Medicare and Medicaid are government healthcare programs for individuals with specific needs. Often, eligibility for the two forms of coverage overlap, and recipients can benefit from both programs.
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However, just because you qualify for one program does not mean you will automatically be eligible for the other. Medicare is a federal program, while Medicaid is a state program, so eligibility qualifications can vary from state to state for Medicaid. Below, we review the differences between Medicare vs. Medicaid and how you can utilize their benefits.
How Can I Be Eligible For Medicaid
Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
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What You Need To Know About Medicaid Combined With Other Insurances
Medicaid is a U.S. entitlement program that pays medical bills for eligible low-income families and qualifying aged, blind, and disabled individuals whose income cant cover necessary medical services. Besides income, other factors may qualify you for Medicaid, depending on your qualifying category.
But you may be wondering if you can qualify for Medicaid and still apply for private health insurance. Well, if your income is low and you have minor children, both you and your children may be eligible for Medicaid, even if you already have private health insurance. But thats just the tip of the icebergtheres more to juggling to achieve the best of both worlds with Medicaid and private insurance.
Learn more about whether you can have both Medicaid and private insurance, your eligibility for both, and how Medicaid works with other health coverage.
How Could Lowering The Medicare Age Affect Benefits For Current Medicaid Enrollees
What is current policy? Medicare and Medicaids benefit packages differ. Both cover inpatient and outpatient care and prescription drugs. Medicare generally includes wider participation of providers, though Medicaid drug coverage is broader. Medicaid also covers long-term care services in nursing homes and the community and specialty behavioral health services, which Medicare generally does not. Medicaid covers dental, vision, and hearing benefits for adults at state option. Traditional Medicare currently does not generally cover these benefits, although most Medicare Advantage plans do offer some dental, vision and hearing benefits. President Bidens budgetcalls for adding these benefits to Medicare. Medicaid rules also require states to recover the cost of long-term care benefits provided to people age 55 and older from the estates of deceased enrollees, and other costs may be subject to estate recovery at state option. Medicare does not require estate recovery, though it also does not cover long-term care services. The appeals process also differs between the two programs, with Medicaid allowing services to continue while an appeal is pending.
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Can You Have Both
People who qualify for both Medicare and Medicaid are considered dual eligible. In this case, you may have original Medicare or a Medicare Advantage plan , and Medicare will cover your prescription drugs under Part D.
Medicaid may also cover other care and drugs that Medicare doesnt, so having both will probably cover most of your healthcare costs.
