Medicare and Medicaid: Complete Guide to Government Health Insurance
Understanding your healthcare options and maximizing your benefits under these essential government programs
64.5M
People enrolled in Medicare (2023)
Source: CMS.gov82.3M
People covered by Medicaid (2023)
Source: Medicaid.gov12.2M
Dual-eligible beneficiaries (2023)
Source: CMS Dual Eligible DataMedicare vs Medicaid Comparison
| Feature | Medicare | Medicaid | |
|---|---|---|---|
| Eligibility | Age 65+ or certain disabilities | Low income and resources | Some qualify for both (dual-eligible) |
| Cost | Premiums ($174.70+ for Part B), deductibles ($1,600+ for Part A), copays vary | Little to no cost, some states have minimal copays | Medicaid may cover Medicare premiums and copays |
| Coverage | Hospital (Part A), Medical (Part B), Advantage Plans (Part C), Prescription (Part D) | Comprehensive coverage including long-term care | Coverage varies by state and plan type |
| Enrollment Periods | Initial (3 months before/after 65th birthday), Annual (Oct 15-Dec 7) | Year-round enrollment if eligible | Special enrollment periods available |
| Provider Network | Any provider accepting Medicare (Original) or network providers (Advantage) | Must use Medicaid-participating providers | Network restrictions vary by plan |
| Income Requirements | No income limits for Parts A/B, income affects Part D assistance | Income limits vary by state and program type | Asset limits also apply for Medicaid |
Medicare Explained
Part A (Hospital Insurance)
Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don't pay a premium if they or their spouse paid Medicare taxes for at least 10 years. 2024 deductible: $1,632 per benefit period.
Hospital stays: Days 1-60 covered after deductible
Skilled nursing: Days 1-20 covered at 100%
Hospice: Fully covered with copays for drugs
Home health: Limited coverage for medical necessity
Part B (Medical Insurance)
Covers outpatient care, preventive services, medical supplies, and some home health care. Most people pay a standard monthly premium ($174.70 in 2024). Annual deductible: $240.
Preventive services: Many at no cost
Doctor visits: 20% coinsurance after deductible
Medical equipment: 20% of Medicare-approved amount
Lab tests: Usually covered at 100%
Part C (Medicare Advantage)
An alternative to Original Medicare offered by private companies approved by Medicare. Combines Part A, Part B, and usually Part D coverage. Often includes extra benefits.
Additional benefits like dental and vision
Annual out-of-pocket maximum protection
Network restrictions may apply
Premiums vary by plan and location
Part D (Prescription Drug Coverage)
Adds prescription drug coverage to Original Medicare. Run by private insurance companies that follow rules set by Medicare. Premiums, deductibles, and copays vary by plan.
Coverage phases including deductible and gap
Formulary determines drug coverage and costs
Extra Help available for low-income beneficiaries
Annual enrollment period for plan changes
Medicaid Explained
Medicaid is a joint federal and state program that provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Each state operates its own Medicaid program while following federal guidelines for coverage and eligibility.
Key Features
State Variation
Each state runs its own Medicaid program within federal guidelines, leading to different eligibility requirements and benefits.
Income limits vary by state and program
Some states expanded coverage under ACA
Benefits packages differ by state
Application processes vary by location
Comprehensive Coverage
Covers essential health benefits including doctor visits, hospital stays, preventive care, prenatal care, and long-term services.
Mandatory benefits required by federal law
Optional benefits vary by state
EPSDT services for children
Long-term care coverage
Cost Sharing
Little to no cost for eligible individuals, though some states may charge small copayments for certain services.
Nominal copays for some services
Cost sharing limits by federal law
Some groups exempt from copays
No annual or lifetime limits
Retroactive Coverage
Can cover medical expenses incurred up to 3 months before application, if eligible during that time.
Must meet eligibility criteria
Coverage for unpaid medical bills
Application within time limits
Documentation requirements
Eligibility Requirements
Medicare Eligibility
You are eligible for Medicare if you meet any of these conditions:
- • Age 65 or older and a U.S. citizen or permanent resident
- • Under 65 with a qualifying disability and received Social Security Disability benefits for 24 months
- • Any age with End-Stage Renal Disease (ESRD) or ALS
- • Worked and paid Medicare taxes for at least 10 years (40 quarters) for premium-free Part A
Medicaid Eligibility
Medicaid eligibility varies by state but generally includes:
- • Low-income individuals and families
- • Pregnant women with income up to 133% of federal poverty level
- • Children under 19 in low-income families
- • Seniors and people with disabilities with limited income and resources
- • Adults in states with expanded Medicaid (income up to 138% of federal poverty level)
Note: Income limits and specific requirements vary by state. Contact your state Medicaid office for details.
Enrollment Process
Medicare Enrollment Periods
Initial Enrollment Period (IEP)
7-month period: 3 months before your 65th birthday month, your birthday month, and 3 months after
General Enrollment Period (GEP)
January 1 - March 31 each year, with coverage starting July 1
Special Enrollment Period (SEP)
Available in special circumstances like leaving employer coverage
Annual Open Enrollment
October 15 - December 7 for changing Medicare Advantage or Part D plans
Most people should enroll during their IEP to avoid late enrollment penalties.
Medicaid Application Process
1. Determine Eligibility
Check your state's Medicaid website or Healthcare.gov to see if you might qualify
2. Gather Documentation
Proof of income, residency, citizenship, and other required documents
3. Submit Application
Apply online through your state Medicaid agency, Healthcare.gov, or in person at a local office
4. Follow Up
Respond to any requests for additional information within required timeframes
Applications are typically processed within 45-90 days. Coverage can be retroactive up to 3 months before application if eligible during that time.
Common Mistakes to Avoid
Missing Initial Enrollment
Not signing up for Medicare when first eligible.
Impact: Lifetime late enrollment penalties
Solution: Mark your Initial Enrollment Period and sign up on time
Ignoring Annual Reviews
Not reviewing coverage during Open Enrollment.
Impact: Paying too much or having inadequate coverage
Solution: Compare plans annually during Open Enrollment
Medicaid Asset Mistakes
Improper asset transfers affecting eligibility.
Impact: Delayed eligibility and coverage gaps
Solution: Consult with Medicaid planning expert before transfers
Coverage Assumptions
Assuming all services are covered.
Impact: Unexpected out-of-pocket costs
Solution: Verify coverage before receiving services
Research-Backed Strategies
Medicare Savings Programs
State programs can save qualified individuals up to $7,200 annually on Medicare costs.
Stats: 48% of eligible seniors don't apply for available assistance programs
Dual Eligibility Benefits
Dual-eligible beneficiaries can save an average of $5,000 annually on healthcare costs.
Stats: Only 53% of eligible individuals are enrolled in both programs
Prescription Drug Coverage
Medicare Part D Extra Help program can reduce drug costs by up to 85%.
Stats: 2.5 million eligible seniors not enrolled in cost-saving programs
Related Guides
Frequently Asked Questions
What's the difference between Medicare and Medicaid?
Medicare is a federal health insurance program primarily for people 65 or older, while Medicaid is a joint federal and state program that helps with medical costs for people with limited income and resources.
Can I have both Medicare and Medicaid?
Yes, some people qualify for both Medicare and Medicaid. These individuals are known as 'dual eligible' beneficiaries. Medicaid can help pay Medicare premiums and other out-of-pocket costs.
When should I sign up for Medicare?
Most people should sign up for Medicare during their Initial Enrollment Period, which begins 3 months before their 65th birthday and ends 3 months after. If you're still working and covered by employer insurance, you may qualify for a Special Enrollment Period.
How do I apply for Medicaid?
You can apply for Medicaid through your state Medicaid agency or through the Health Insurance Marketplace. Each state has different eligibility requirements and application processes.
What does Medicare Part A cover?
Medicare Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.
Calculate Your Medicare Costs
Use our calculator to estimate your Medicare costs and find available savings programs