AA

Back to UNDERSTAND ENROLLMENT

A Guide to Medicare and Medicaid

by: Margie Johnson Ware, Aging and Health Specialist

Medicare and Medicaid are two separate health insurance programs that were created in 1965 and designed to provide coverage for vulnerable populations. Currently, there are over 137 million people covered by Medicare and Medicaid.

This article reviews four key questions on the differences, services, enrollment and cost of Medicare versus Medicaid:

1. The difference between Medicare and Medicaid

The main difference between Medicare and Medicaid is that Medicare is health insurance based on age/disability, and Medicaid is based on income. Applicants eligible for Medicare must be age 65 or older, or between the ages of 18-64 and qualify for Social Security Disability Insurance (SSDI) or have End-Stage Renal Disease. Find out if you are Medicare eligible.

Medicaid covers a wide range of individuals with low income, including families, pregnant women, children, persons with disabilities and individuals receiving Supplemental Security Income (SSI). A person can qualify for both Medicare and Medicaid. This is sometimes called being a “dual” or “dually eligible” for the programs. Roughly 10 million Americans are enrolled in both programs.

2. Services do Medicare and Medicaid cover

Both Medicare and Medicaid cover inpatient and outpatient care, which includes hospitals, doctors, emergency services and preventive care. Medicaid also covers long-term care services, such as in-home and nursing home care, whereas Medicare only covers short-term home health or skilled nursing facility services, such as rehabilitation following a hospital stay.

Medicare and Medicaid may also offer a range of other services by purchasing additional coverage (such as Part C/Medicare Advantage, Part D drug plans, and Medigap supplemental insurance) under Medicare or if your state chooses to cover them under Medicaid.

3. Medicare/Medicaid enrollment

In order to enroll in Medicare, the application must occur during one of three enrollment periods. The most common time to enroll is during the Initial Enrollment Period (IEP), the 7-month window surrounding your 65th birthday. If the IEP is missed, enrollment is also available during the General Enrollment Period (Jan-March each year), or during a Special Enrollment Period. There is also an annual Open Enrollment Period (Oct. 15- Dec. 7) allowing for joining/switching/dropping a Medicare Advantage or Part D prescription drug plan.

The application for Medicare is submitted through Social Security. Those with SSDI because of a disability do not have to apply due to automatic enrollment in Medicare after two years on SSDI.

Medicaid does not have a specific enrollment period, so applications can be submitted anytime. Each state has specific income rules, and the state Medicaid agency can help determine qualification.

4. Cost of Medicare and Medicaid

Everyone with Medicare pays for a portion of the expenses, but how much is paid depends on the type of coverage – Parts A & B, Part C/Medicare Advantage, Part D and/or Medigap. The costs of Medicare include premiums, deductibles and copayments/coinsurance. To learn more about the specific cost for Medicare coverage, check out Make Sense of Medicare Costs. For people concerned about the cost of Medicare, there are programs to help pay those costs.

Medicaid costs depend on income and an individual state’s payment coverage for services. Costs can include premiums, deductibles and copayments/coinsurance. Out-of-pocket costs typically apply to all Medicaid enrollees, but most are limited to very small amounts except those exempted by law. Learn more about Medicaid costs.

It is your right to access any health program for which you meet the requirements; never assume that you don’t qualify for Medicare or Medicaid. The following three resources offer free professional advice on enrollment, costs and more:

  1. Your local State Health Insurance Assistance Program (SHIP) is federally funded to provide free, unbiased counseling on Medicare

  2. Your local Area Agency on Aging or Aging and Disability Resource Center can provide information and assistance with health insurance options

  3. Our Medicare Questionnaire will give you an in-depth assessment of your situation and personalized recommendations for next steps

The following three resources offer free professional advice on enrollment, costs and more:

  1. Your local State Health Insurance Assistance Program (SHIP) is federally funded to provide free, unbiased counseling on Medicare

  2. Your local Area Agency on Aging or Aging and Disability Resource Center can provide information and assistance with health insurance options

  3. Our Medicare Questionnaire will give you an in-depth assessment of your situation and personalized recommendations for next steps