Medicare and Medicaid are different government-funded healthcare programs. Sometimes, a person may be eligible for both.
An estimated 12 million people in the United States are dually eligible for Medicare and Medicaid, according to Medicaid.gov.
In this article, we discuss eligibility for Medicare and Medicaid, as well as what to know about each program.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Dual-eligible beneficiaries are people who have both Medicare and Medicaid. Each state is responsible for determining Medicaid coverage, and, as such, Medicaid benefits may vary.
Receiving both Medicare and Medicaid can help decrease healthcare costs for those who are often most in need of treatment.
As a general rule, Medicare will usually first pay for health services, and Medicaid will then cover any differences up to its payment limits.
Of those who are dual-eligible, an estimated two-thirds meet the requirements for Medicare based on age, according to an article in the journal Health Affairs. The remaining one-third of dual-eligible individuals meet the requirements based on a disability.
There are a few key differences between Medicare and Medicaid.
Medicaid is a health insurance program providing financial assistance to individuals and families with a low income or limited financial resources.
The federal government sets rules and regulations regarding Medicaid, and individual states are responsible for operating Medicaid programs.
People of all ages can apply for Medicaid. Medicaid programs may cover children, families, pregnant women, those with disabilities, and older adults.
Medicare is an insurance plan for people at or over the age of 65 and for others with qualifying medical concerns.
A person must meet eligibility criteria based on their work history or that of their spouse. They can qualify for premium-free hospital coverage and pay a premium for medical and prescription drug coverage.
A person does not have to meet any income-related criteria to qualify for Medicare.
The usual way to qualify for Medicare is to be 65 years of age.
A person can receive premium-free Part A (hospital coverage) benefits if they or their spouse is 65 or older and has paid sufficient Medicare taxes through previous employment.
They can also qualify for Medicare Part B, which is medical coverage for doctor visits and many other medical-related expenses.
Some people younger than 65 can be eligible for Medicare, including those with:
- end stage renal disease
- amyotrophic lateral sclerosis
Some people, such as those with disabilities, may have a waiting period before they can qualify for Medicare.
Those who are dual-eligible often have chronic conditions and functional limitations that require more medical care.
On average, Medicare spends twice as much on a dual-eligible individual as on a person who qualifies for Medicare alone.
Eligibility for Medicaid depends on the region where a person lives, as some states have different criteria for qualification.
Medicaid standards can change every year. If a person was unsuccessful in a prior application, they might qualify at a later date.
One of the most important factors for Medicaid eligibility is where a person falls on the Federal Poverty Level (FPL).
The FPL, which the Department of Health and Human Services (HHS) sets every year, establishes a person’s eligibility for specific programs.
There is an FPL for the 48 contiguous states and the District of Columbia, with a higher FPL in Alaska and Hawaii. The FPL varies according to a family’s size.
To be eligible to receive both Medicare and Medicaid, a person will need to qualify for either partial-dual or full-dual coverage.
Eligibility for partial-dual coverage depends on the support that a person receives from Medicaid. Examples of the varied coverage may include:
- Part A premium (if applicable)
- Part B premium
Those who qualify for full coverage under Medicare and Medicaid may receive all of the benefits for which partial-dual enrollees qualify plus additional benefits, such as long-term care services.
Medicaid provides a variety of programs based on a person’s FPL. Examples include programs that help pay for prescription drugs.
Medicaid benefits and coverage can vary widely among states. Some states may expand their Medicaid coverage beyond traditional income limits.
The Medicaid website can help a person find the services that are available to them based on their geographical location.
Medicaid is not the only government-sponsored resource that helps pay for medical costs. An individual can also apply for Extra Help, a program that helps beneficiaries with Medicare Part D, which covers prescription drug costs.
A person can visit Medicare’s website to find out more about getting and applying for Extra Help.
A person may qualify for both Medicare and Medicaid based on their health and income level.
Medicare will usually pay for health expenses first, while Medicaid may help pay for out-of-pocket and noncovered expenses.
Medicaid coverage varies depending on each state’s rules and income level requirements.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.