Last Updated on October 13, 2021 by Ian Evans
Medicare and Medicaid benefits are government-backed healthcare programs. They serve different groups of people and have different eligibility requirements. Some people may qualify for both programs.
It’s important to understand the differences between Medicare and Medicaid benefits. Each one works so that if you’re eligible for either or both, you can receive all the benefits offered to you.
What is Medicare?
Medicare is a federal program that provides healthcare coverage in “parts.” Part A provides coverage for hospital insurance. Part B provides coverage for outpatient services.
When people refer to Medicare, they usually mean Original Medicare. This consists of Part A and Part B.
Medicare Advantage, also known as Medicare Part C, covers everything in Original Medicare. It helps bundle Part A and Part B into a single plan. These plans usually include additional benefits that Original Medicare doesn’t offer. It is provided by private insurers who follow guidelines set by the government.
People at least 65 years of age who are U.S. citizens or permanent residents are eligible for Medicare. Most people eligible for Social Security are also eligible for Medicare.
People younger than 65 with certain disabilities also qualify. Those with kidney issues also qualify for both Medicare and Medicaid benefits.
What Does Medicare Cover?
Original Medicare covers hospital stays, skilled nursing, home health care, and hospice care. It also covers doctor’s visits, mental health services, therapy, and other outpatient services.
Original Medicare doesn’t cover prescription drugs, eyeglasses, hearing aids, or dental care. People who choose Original Medicare can buy prescription drug coverage.
Medicare Advantage covers everything included in Original Medicare. Most Medicare Advantage plans also include prescription drug coverage. It frequently offers dental and vision coverage, hearing aids, and fitness benefits. These coverages vary by Medicare and Medicaid benefits plan.
Medicare comes with a Cost
- Part A- pays for hospital services, is free if you or your spouse paid Medicare payroll taxes for at least 10 years. (People who aren’t eligible for free Part A can pay a monthly premium of several hundred dollars.)
- Part B- covers doctor visits and outpatient services. It comes with a monthly price tag—the standard premium in 2020 was $144.60 per month and rose to $148.50 in 2021.
- Part D- covers prescription drug costs. It also has a monthly charge that varies depending on which plan you choose.
The average Part D basic premium in 2021 is about $30 a month, roughly the same as last year. Besides premium costs, you’ll also have co-payments, deductibles, and other out-of-pocket costs.
Consider Medigap Options For Yourself
Beneficiaries of traditional Medicare will sign up for a Medigap supplemental insurance plan. Private insurance companies offer these to help cover deductibles, co-payments, and other gaps.
You can switch Medigap plans at any time. But you could be charged more or denied coverage based on your health. If you choose or change plans more than six months after you first signed up for Part B.
Medigap policies go from A and N. Each policy with the same letter must offer basic benefits. Usually, the only difference between same-letter policies is the cost.
Plan F is the most popular policy because of its comprehensive coverage. But as of 2020, Plan F (along with Plan C) is unavailable for new enrollees. The closest substitute for Plan F is Plan G. It pays for everything that Plan F did except the Medicare Part B deductible. Anyone enrolled in Medicare before 2020 can still sign up for plans F and C.
You can choose to sign up for traditional Medicare: Parts A, B, and D, and a supplemental Medigap policy. Or you can go an alternative route by signing up for Medicare Advantage.
This provides medical and prescription drug coverage through private insurance companies. Also called Part C, Medicare Advantage has a monthly cost. The Part B premium varies depending on which plan you choose.
With Medicare Advantage, you don’t need to sign up for Part D or buy a Medigap policy. Like traditional Medicare, you’ll also be subject to co-payments, deductibles, and other costs. In many cases, Advantage policies charge lower premiums than Medigap plans.
But do keep in mind, they have higher cost-sharing. Your choice of providers may be more limited with Medicare Advantage than with traditional Medicare. Recent research has found that sicker enrollees dump Medicare Advantage for Original Medicare.
What Medicare does Not Cover?
While Medicare covers your health care, it generally does not cover long-term care. This is an important distinction. Under certain conditions, particularly after a hospitalization, to treat an acute-care episode. Medicare will pay for medically necessary skilled nursing facilities or home health care.
But Medicare generally does not cover costs for “custodial care.” Care that helps you with activities of daily living, such as dressing and bathing. If you meet the income and asset requirements, you will have to rely on your savings, long-term-care insurance, or Medicaid to cover those costs. Traditional Medicare also doesn’t cover routine dental or eye care and some items such as dentures or hearing aids.
What Is Medicaid?
Medicaid is a joint program between the government and states. It ensures people with low incomes have healthcare access.
Medicaid provides health coverage for the following:
- families and children,
- pregnant people,
- the elderly,
- people with disabilities, and
- some people with low incomes.
In the 39 states (including Washington, D.C.), most adults under 65 who have an income lower than 138% of the federal poverty level are eligible. In 2021, that amount is $12,880 for an individual and $21,960 for a family of three.
If you live in one of the 12 states that chose not to expand Medicaid, coverage for nonelderly adults is limited. This is especially true for people who have a child, pregnant women, or people who have a disability.
What Does Medicaid Cover?
Some benefits must be offered in all plans across all states, according to federal guidelines, including:
- Coverage for hospital stays
- Outpatient hospital services
- Laboratory and X-ray services
- Family planning services
- Nursing facility services
- Home health services
- Doctor visits
- Transportation to medical care
Some of the optional benefits states can choose to offer include:
- Prescription drugs
- Physical therapy
- Occupational therapy
- Speech, hearing, and language disorder services
- Respiratory care services
- Optometry services
- Dental services
Medicare vs Medicaid- What Is The Better Option For Seniors?
Medicare and Medicaid can be confusing, partly because the names sound so similar.
But they’re two very different government healthcare programs.
Medicare focuses on adults aged 65 and older, and Medicaid focuses on low-income individuals and families. The benefits, costs, and eligibility requirements are different for each program. Neither program has automatic enrollment, so it’s important to understand what each one offers.
Knowing which to apply for helps maximize your older adult’s healthcare benefits. The first and biggest difference between Medicare and Medicaid is who’s eligible for each program.
Because of the different eligibility rules, some people who qualify for Medicaid won’t qualify for Medicare and vice versa. The second key difference is that Medicaid covers long-term care services and support. Medicaid is the nation’s largest single source of long-term care funding.
If it’s deemed medically necessary, Medicaid can cover the cost of:
- nursing homes,
- assisted living communities, and
- other long-term care alternatives.
Generally, Medicare only covers short-term stays in skilled nursing facilities after a hospitalization.
Consider Dual Eligibility
People who qualify for both Medicare and Medicaid are considered dual-eligible. In this case, you may have original Medicare (parts A and B) or a Medicare Advantage plan (Part C). Medicare will cover your prescription drugs under Part D.
Medicaid may also cover other care and drugs that Medicare doesn’t. So, having both will probably cover most of your healthcare costs. Medicare and Medicaid are two U.S. government programs. Both are designed to help different populations get access to healthcare.
Medicare covers citizens aged 65 and over and those with certain chronic conditions or disabilities. In contrast, Medicaid eligibility is mainly based on income level and need. Beneficiaries with Medicare and Medicaid are dual-eligible. They account for about 20 percent of Medicare beneficiaries (12.1 million people). Dual eligibility is categorized based on whether they receive partial or full Medicaid benefits.
A Better Option
Time to sign up for Medicare. Full-benefit dual-eligible have comprehensive Medicaid coverage. While partial benefit, you may get help with premiums and cost-sharing through a Medicare Savings Program (MSP). (Some beneficiaries have Medicare, Medicaid, and an MSP.)
The federal government oversees Medicare eligibility – meaning it is the same in each state. But states set their own eligibility rules for Medicaid and the MSPs (within federal guidelines). Income limits for these programs vary widely.
With dual-eligible Medicare and Medicaid benefits, Medicare pays first, and Medicaid pays last. But this is not the case for things Medicare doesn’t cover, like long-term care. If Medicaid covers long-term care, Medicare will still be the primary payer for any Medicare-covered services. This includes services like skilled nursing care or physical therapy.
Although it is less common, if a dual eligible individual has additional coverage (such as a Medigap plan), then Medicare pays. First, Medigap will pay second, and Medicaid is the last payer for their claims (for expenses covered by all three).
What is the Income Range for Beneficiaries who are Dual-Eligible?
Generally, beneficiaries earning less than 135 percent of the federal poverty level are eligible for the MSP. If they have limited savings (although some states don’t require beneficiaries to have low assets). This equates to $17,226 annually for single beneficiaries and $23,274 for married couples. Beneficiaries qualify for full Medicaid benefits if their incomes and assets are even lower (but the exact amounts vary by state).
Many seniors who live in nursing homes are dual-eligible. They qualify for Medicare based on their age and Medicaid because of their financial circumstances. It is also common for Medicare beneficiaries under 65 to receive Medicaid benefits.
Can I select an Insurance Plan for my Medicare and Medicaid Benefits?
If you are dual-eligible, you can enroll in a dual-eligible special needs plan (D-SNP) that covers both Medicare and Medicaid benefits. These plans may also pay for expenses that Medicare and Medicaid don’t cover individually. They include over-the-counter items, hearing aids, and vision or dental care.
Beneficiaries who are dual-eligible can change between Original Medicare and Medicare Advantage. Alternatively, they switch Part D plans each quarter.
Medicare and Medicaid benefits are a difficult and complex topic. Most people don’t really understand what the difference between these two plans is. You can learn more about it by learning more about their prospective plans.
Healthcare insurance is important and it’s necessary to understand the difference between these two plans. So, make sure that you understand before you make the decision. BoomersHub is here to guide you with any confusion you may have.