Medicare Is Not Medicaid and Medicaid Is Not Medicare, But Some People Can Qualify For Both

Michael T. Braden, November 2, 2023 MEDICARE VS MEDICAID

Chart Showing Medicare vs Medicaid

MEDICARE IS NOT MEDICAID

Medicare is not Medicaid, and Medicaid is not Medicare.

I wanted to write this article for anyone, especially those turning 65 next year. You see, there is a big misunderstanding about Medicare and Medicaid, with many people thinking they are the same. In reality, they are not similar at all. Hopefully, this article will help to explain and educate everyone on the differences between Medicare and Medicaid.

Most people are confused and believe that Medicare and Medicaid are the same thing. Similar to Medicare Supplements and Medigap being the same. However, there is a stark difference. Medicare is the National Health Insurance Program for Americans age 65 and over, as well as those with ALS or Renal Failure, or those who have been issued a Disability designation by the Social Security Administration. Medicaid operates at the state level and helps provide Health Care and other vital services to low-income individuals, seniors, single mothers, and children.

Medicare and Medicaid are very different programs created by the U.S. government to cover the medical bills of two distinct groups of Americans.

Medicare is the National Health Insurance Program for Americans age 65 and older, along with individuals diagnosed with a Disability, those with ALS, and anyone diagnosed with End Stage renal Disease.

Medicaid is a Government Assistance Program for low-income individuals of any age. Although they receive subsidies and funding from the Federal Government, Medicaid is run by each state, so even though the programs are similar, each state has its own way of doing things. For example, in California, its Medicaid Program is referred to as Medi-Cal.

To qualify for Medicaid benefits, an individual must fall below the income guidelines.

Medicare is the National Health Insurance Program for individuals 65 and older in the US. Medicaid is for families, Children, and those with low incomes. The Federal Government and Medicaid manage Medicare, which is managed by each state.

ELIGIBILITY GUIDELINE FOR MEDICARE & MEDICAID

One of the most significant differences between Medicaid and Medicare is who qualifies for coverage. Here’s all you need to know about how Medicare and Medicaid eligibility differ.

MEDICARE IS NOT MEDICAID

Who qualifies for Medicare? People who are 65 or older qualify for Medicare as long as they’re both naturalized U.S. citizens and Resident Aliens who have Green Cards and have been granted Full-Time Citizenship Status, or lawful permanent residents.

MEDICAID IS NOT MEDICARE

As for who qualifies for Medicaid, that differs from state to state, but it always provides health coverage to individuals who:

•  Have extremely Low Incomes (with or without children).

•  Individuals who have been classified as having one or more disabilities.

•  Women who are Pregnant.

•  Seniors

Many states extend Medicaid coverage beyond what federal law requires. For example, most have expanded their programs to cover nearly all low-income residents. Other state Medicaid programs cover people receiving home- and community-based services and children in foster care.

Did you know that Medicare covers more than 60 million Americans, while Medicaid has nearly 73 million beneficiaries nationwide?

DUAL ELIGIBLE DEFINITION

Individuals referred to as Dual Eligible are those who meet the eligibility criteria for both Medicaid and Medicare.

You might be surprised that, according to the United States Government, there are more than 12 million people in America who are "Dual Eligible Members". 12 Million! That is a lot of people.

Dual Eligibility Chart For Individuals Who Qualify for Medicare and Medicaid.

Typically, an individual meets the requirements for Dual eligibility by being classified as a low-income senior Citizen (Seniors are age 65 and older). Or anyone of any age who has received a person with a Full-Time Disability from the Social Security Administration.

If you have Medicare and Medicaid coverage, Medicaid may help with your Medicare premiums and out-of-pocket expenses, such as deductibles and copayments. Additionally, there are benefits for Skilled Nursing Care that extend beyond Medicare's 100-Day Skilled Nursing Care Limit.

For anyone who meets the definition of a Dual Eligible person, Medicare always pays first, and Medicaid is the secondary payer, at least until you reach any limits in each state.

ENROLLMENT IS DIFFERENT FOR MEDICAID AND MEDICARE

YOUR MEDICARE ENROLLMENT

If you want Medicare coverage, you have to sign up during specific enrollment periods.

Most people first become eligible for Original Medicare, which is another name for Medicare Part A and Part B, during the initial enrollment period (IEP). This seven-month window of time includes:

•  The three months before you turn 65

•  The month you turn 65

•  The three months after you turn 65

People who miss signing up for Medicare Parts A and B — or for a Medicare Advantage plan — during the IEP have to wait until the next general enrollment period rolls around to do so. The Medicare general enrollment period goes from Jan. 1 to March 31 every year.

Another way to get Medicare after the IEP is to qualify for a special enrollment period.

Will you start receiving Social Security or Railroad Retirement Board (RRB) benefits at least four months before your 65th birthday? If so, you don’t need to worry about the dates above. You'll automatically get Original Medicare.

If you want Medicare but you don’t get Social Security or RRB benefits four months before you turn 65, you can apply online or at a local Social Security office.

Most people enroll in Medicare prescription drug coverage during the enrollment periods detailed above, if they decide to enroll at all.

You can choose not to enroll in a prescription drug plan when you first become eligible for it. If you do that, though, you’ll pay a late penalty for not enrolling in a Medicare Part D Prescription Drug Plan within 63 Days of your Part B Eligibility Date. And, to make matters worse, this penalty never goes away. On average, they add 38 cents per month for each month you did not have a Prescription Drug Plan in force, and that amount is added to each month's premium. So instead of $7.40 Premium each month, you went 3 years without credible coverage (36 x .38 = $13.68). You will now pay $13.68 in penalties forever, meaning your $7.40 Premium is now $21.28 each month!

YOUR MEDICAID ENROLLMENT

With Medicaid, there are NEVER any penalties to worry about, and you will never need to worry about any dates or deadlines.

You do have to apply and qualify for this health coverage, though. And you are eligible for Medicaid based on your income. These income requirements vary slightly from state to state. You should contact your state's Medicaid Department for the exact eligibility requirements for your area.

We recommend that you contact your state Medicaid agency to apply for this kind of coverage. Another way to apply for Medicaid is through the health insurance marketplace established by the Affordable Care Act (Obamacare).

BENEFITS AND COVERAGE ARE VASTLY DIFFERENT

Both Medicare and Medicaid cover many medical procedures and costs. They do so in different ways and to various extents, though.

YOUR BENEFITS UNDER MEDICARE

Medicare coverage is a lot more complicated than Medicaid coverage. Medicare consists of four main parts: A, B, C, and D.

MEDICARE PART A

Medicare Part covers your inpatient costs and Benefits. Medicare Part A primarily covers hospital costs.

MEDICARE PART B

Medicare Part B covers your Outpatient Care and Services.

MEDICARE PART C = MEDICARE ADVANTAGE

Medicare Part C is also known as Medicare Advantage. You get Medicare Advantage (Part C) plans through private insurance companies. They provide the same coverage as Part A and Part B. Sometimes, they cover care that Original Medicare doesn’t, like dental work, hearing tests, and prescription drugs.

MEDICARE PART D (PRESCRIPTION DRUG COVERAGE)

Medicare Part D covers prescription drugs. Not all Part D plans cover all drugs, though. Some plans may cover the medications you take, while others won't. Because of this, it's essential to review a plan's list of covered drugs, or "formulary,” before you join it.

YOUR COMMON BENEFITS WITH MEDICAID

Medicaid coverage is more straightforward than Medicare coverage, but that doesn’t mean it’s always easy to understand. That’s because although all state Medicaid programs must provide certain benefits, they can choose whether to give others.

Here are some of the Medicaid benefits every state must offer:

•  Inpatient and outpatient hospital services

•  Doctor visits

•  Lab tests

•  X-rays

•  Family planning services

•  Home health services

•  Nursing facility services

And here are some of the optional Medicaid benefits states can offer:

•  Chiropractic care

•  Dental care

•  Eyeglasses

•  Prescription drugs

•  Physical therapy

•  Speech, hearing, and language disorder services

•  Other diagnostic, screening, preventive, and rehabilitative services

TYPICALLY BENEFICIARIES SPEND LESS MONEY ON MEDICAID THAN THEY DO IN MEDICARE

Another key difference between Medicare and Medicaid is how much they cost.

The main difference between the two programs is that people with Medicare pay a larger share of the cost of covered procedures and services than Medicaid recipients do.

In fact, people who get Medicaid usually pay no part of the costs for covered medical care. Sometimes they’re charged a small copay, but that’s about it.

Medicare recipients, though, often have to pay premiums, deductibles, and other out-of-pocket costs for coverage. And not only that, but they usually pay them for multiple Medicare “parts.”

For example:

•  Most Americans don't pay a premium for Part A; those who do pay up to $437 each month. 

•  Most people pay a premium for Medicare Part B. The standard amount is $164.90 per month, though it could be higher depending on your income. 

•  Medicare Part D recipients usually pay monthly premiums, too. How much they pay depends on the drug plan they choose.

  
  

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