How to Qualify for Medicare and Medicaid

• Medicare and Medicaid are separate healthcare programs. Medicare is based on age and Medicare taxes while Medicaid is based on income level.

• Some people can qualify for Medicare and Medicaid, a program known as the Dual Eligibles. 

In 1965, the federal government introduced both Medicaid and Medicare. Despite the similar-sounding names, Medicare and Medicaid are two different programs, each one having different eligibility rules and coverage. 

That said, some Americans are actually eligible for both Medicare and Medicaid coverage. This program is known as the Medicare-Medicaid Dual Eligibles Program. This article will explain how to qualify for Medicare and Medicaid.

The Federal Medicare Program provides health insurance for people age 65 and older, younger Americans with certain disabilities, or those with end-stage renal disease (ESRD). There are two main ways to sign up for Medicare coverage. Enrollees can either enroll in an Original Medicare plan or a Medicare Advantage plan.

What Is Original Medicare? 

Original Medicare is the first iteration of the federal program known as Medicare. Original Medicare benefits are divided into two Medicare Parts. Each of these portions covers specific types of healthcare services. The Parts of Original Medicare are called Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

While Original Medicare coverage is quite comprehensive, Medicare does not cover everything. Some examples of what is not covered by Medicare include: 

• Dental coverage

• Vision coverage

• Hearing coverage

• Prescription drug coverage

Original Medicare beneficiaries can still get coverage for prescription drugs but would need to sign up for a Medicare drug plan in order to receive that coverage. These plans are known as Medicare Part D. 

How Much Does Medicare Cost? 

Medicare costs change annually, and these costs vary based on a variety of factors, including other health insurance the beneficiary may have, as well as the beneficiary’s location, income, and more. 

For most beneficiaries, Medicare Part A is cost-free. However, Part B requires monthly premiums that are often deducted from a beneficiary’s Social Security or Railroad Retirement benefits.

What Is Medicare Advantage? 

Medicare Advantage plans, also known as Medicare Part C or MA plans, are supplemental Medicare plans. Medicare Advantage plans bundle Medicare Part A and Part B into one health insurance plan. MA plans are offered through private insurers that are Medicare-approved.

Most Medicare Advantage plans also have additional benefits, including dental, hearing, and vision coverage. MA plans also often include Medicare Part D within its policies. 

Those who worked and paid Medicare taxes for at least 10 years are eligible to sign up for Medicare around age 65. Other people eligible for Medicare include:

• Americans 65 and younger with disabilities

• Americans 65 and younger with end-stage renal disease (ESRD)

• Spouses

Note: Learn more about Medicare eligibility at this resource.

Medicaid is a joint federal and state program that provides health coverage for over 76 million Americans. Medicaid was designed to cut health care costs for those with limited income.

While Medicaid benefits vary by state, the United States Government mandates the following services by covered: 

• Inpatient hospital services

• Outpatient hospital services

• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services

• Nursing Facility Services

• Home health services

• Physician services

• Rural health clinic services

• Federally qualified health center services

• Laboratory and X‑ray services

• Transportation to medical care

• And more…

There are also optional Medicaid benefits states can include within their Medicaid coverage such as prescription drugs, eyeglasses, physical therapy, and others. 

How Much Does Medicaid Cost? 

Medicaid costs will differ from state to state. Interested persons should contact their state’s Medicaid office for more information. 

Those eligible for Medicaid generally include low-income adults, children, pregnant women, elderly adults, people with disabilities, and those receiving Supplemental Security Income (SSI). Each of these groups is referred to as a mandatory eligibility group. According to federal law, these groups are entitled to Medicaid coverage.

Individual states can choose to cover additional groups, such as Americans receiving home and community-based care. 

However, Medicaid eligibility isn’t that straightforward. There are certain criteria that must be met within each of those groups in order to be eligible. The Affordable Care Act created a new set of requirements based on financial eligibility and non-financial eligibility. 

Note: Learn more about Medicaid eligibility at this resource.

The Medicare-Medicaid Dual Eligibles program is for beneficiaries eligible for both Medicare benefits and Medicaid benefits. Currently, 12 million Americans are dually eligible for both Medicaid and Medicare benefits. 

Eligibility for the Dual Eligibles program is based on Social Security Administration income methodologies. These methodologies are determined by where someone falls under the Federal Poverty Level. 

Medicare Savings Programs are Medicaid programs for Medicare beneficiaries with limited income and resources. These programs help beneficiaries pay for their Medicare benefits. For example, some of these programs pay Medicare premiums, such as the Medicare Part B monthly premium.

There are four types of Medicare Savings Programs:
 

• Qualified Medicare Beneficiary (QMB)
• Specified Low-Income Medicare Beneficiary (SLMB)
• Qualifying Individual (QI)
• Qualified Disabled Working Individual (QDWI)

Each program will have different income and resource eligibility limits. Learn more about Medicare Savings Programs at this resource.

Does Medicare or Medicaid pay first?

When you're dual eligible, Medicare pays first, and Medicaid pays second. Medicaid never pays first for services covered by Medicare. Medicaid will only pay after either Medicare, employer group health plans, and/or Medicare Supplement (Medigap) Insurance plans have paid.

For example, services such as primary care visits, skilled nursing facility care, home care, and more are eligible for both Medicare and Medicaid coverage. In these scenarios, the service will first be covered by Medicare while Medicaid covers final payments such as copays or coinsurances.

How does someone apply for Medicaid?

Every state will have different rules for both Medicaid eligibility and applying. Interested persons should contact their local Medicaid office or call 1-800-MEDICARE for more information.

What does the Medicaid “spend down” mean?

For those whose incomes exceed the Medicaid income limits, some states allow interested persons to “spend down” to become eligible for the Medicaid program. The “spend down” process allows potential beneficiaries to subtract their medical expenses from their income.

Note: Find a Medicare-Medicaid plan here.