A Guide to Medicare and Medicaid – Which Program Can I Enroll In?

September 11, 2017

by: Margie Johnson Ware, Aging and Health Specialist

You have probably heard the terms Medicare and Medicaid many times, whether it be on your local news station, internet searches, or when talking to your friends. While most people know these two terms are associated with health care, they may not understand what they are.

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 120 million people covered by Medicare and Medicaid. But what is the difference between these two programs? What do they cover, and who can enroll?

1. What’s 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.

To be eligible for Medicare, you 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.

Medicaid covers a wide range of individuals with low incomes, 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. What services do Medicare and Medicaid cover?

Both Medicare and Medicaid cover inpatient and outpatient care, which includes hospital, doctor, 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 if you purchase 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. When & how can I enroll in Medicare/Medicaid?

In order to enroll in Medicare, you must apply during one of three enrollment periods. The most common time to enroll is during your Initial Enrollment Period (IEP), the 7-month window surrounding your 65th birthday. If you miss your IEP, you can also enroll during the General Enrollment Period (Jan-March each year), or during a Special Enrollment Period, if you qualify. There is also an annual Open Enrollment Period (Oct. 15- Dec. 7) during which you can join/switch/drop a Medicare Advantage or Part D prescription drug plan.

You apply for Medicare through Social Security. If you receive SSDI because of a disability, you do not have to apply; you will be automatically enrolled in Medicare once you have been on SSDI for two years.

Medicaid does not have a specific enrollment period, so you can apply to receive coverage at any time of the year. Each state has its own income rules, however, so you must see if you qualify and apply through your state Medicaid agency.

4. What do Medicare and Medicaid cost?

While the costs for both Medicare and Medicaid can vary, the reasons for variations greatly differ.

Everyone with Medicare will pay for a portion of their expenses, but what you pay depends on the type of coverage you have – Parts A & B, Part C/Medicare Advantage, Part D and/or Medigap. The costs of Medicare include premiums, deductibles, and copayments/coinsurance. You can learn more about the specific cost for Medicare coverage on our page “Make Sense of Medicare Costs.” For people who have trouble affording Medicare, there are some programs to help pay those costs.

Medicaid costs depend on your income and individual state’s payment for a particular service. 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 resources offer free professional advice on enrollment, costs, and more: