Medicare vs. Medicaid Plan: Your Complete Guide

Medicare and Medicaid are two health insurance programs covering almost 100 million Americans. That’s a massive number, isn’t it? Although these two programs sound the same, they are completely different. Let’s unpack their differences and take you through the comparison of the Medicare vs Medicaid plan.

Medicare vs. Medicaid Plan: The Basics

Medicare and Medicaid are both government-owned programs, providing health coverage to millions of coverages. However, both differ in the coverage allowances, eligibility criteria, and costs.

Medicare is, in fact, a federal program providing health coverage to people aging 65-year-old individuals. On the other hand, Medicaid is a state and federal program that provides health coverage to low-income families. Let’s discuss the eligibility in more detail.

Eligibility Criteria

Who is eligible for Medicare?

Medicare is not only restricted to people aging 65 or more. In addition, it can be extended to:

Individuals aging 50 or more and receiving disability benefits
A government’s officer children, provided he/she duly paid taxes
Individuals diagnosed with ALS and ESRD

Who is eligible for Medicaid?

Medicaid, on the other hand, has minimum income requirements varying according to state. If your income falls below the poverty level as per your state guidelines, you can qualify for it. Usually, the eligible income level for Medicaid is 133% lower than the federal poverty level.

Moreover, Medicaid has special programs that extend coverage to certain individuals, such as pregnant women and people with challenging medical needs.

Medicare vs. Medicaid Plan Coverage Benefits

Medicare has specific parts: Part A and Part B. Part A usually covers hospitalization services, while Part B deals with outpatient coverages. Moreover, there are Medicare advantage plans (type C) which provide Type A, Type B, and any additional coverage in a consolidated single plan.

Prescription Medication coverage (Type D) is another essential prescription plan and sells separately from Original Medicare. However, some Medicare Advantage plans can provide Part D coverage as well. You can also have Medicare savings account with a Type C health plan.

On the other hand, Medicaid coverage benefits vary from State to State. However, it offers plenty of valuable services such as hospitalization, clinic treatment, doctor and lab services, nursing, and midwife services. However, states can add more coverage options such as prescription, dental, vision, and therapy services. Sometimes, Medicaid can even support long-term care, which is not an option with Medicare.

Medicare vs. Medicaid Plan Costs

Medicare only has a premium cost for Type B. However, it can have massive deductibles (in the case of Type A), and Medicare covers only 80% of total services. You have to pay the rest 20% in the form of coinsurance.

Moreover, if you’re a social security recipient, you are saved from rising premiums per the Medicare hold harmless provision ruling. In contrast, Medicaid recipients don’t have to pay for healthcare services. Even if they do, it’s in the form of low copays, i.e., usually $50. States can also charge limited premiums to certain people, especially pregnant women, and disabled individuals with a household income 150% above the poverty line.

Who gets the Medicare?

People 65 or older, those under 65 who are disabled, and those with End-Stage Renal Disease are the primary beneficiaries of Medicare (permanent kidney failure requiring transplant or dialysis).

Medicare plans Part A covers hospital bills, Part B everything else. Having paid Medicare taxes for 10 years makes Part A free. To qualify for Medicare Part A free of premiums once you turn 65, you must either:

Social Security or Railroad Retirement Board Retirees If you qualify for
Social Security or Railroad Retirement but haven’t applied, do the following:
Either you or your spouse worked for a government agency that participated in Medicare.

What is Medical vs. Medicare?

Medicare covers hospitalizations, clinic visits, doctor’s appointments, and screenings. Also, Medicare is only for persons 65+ or disabled. All 50 states are eligible.

Medi-Cal helps low-income Californians with health coverage. This federal-state program gives low-income people health coverage. Low-income Californians of any age can get Medi-Cal.

Medicare: How It Works

The original Medicare program is government-run health insurance. There are two parts to this: Part A & B.

Part A covers the majority of the costs associated with hospital stays for program participants. At the same time, Part B helps cover the costs associated with outpatient care at doctors’ offices and allied health services.

Alternative Medicare plans are available. The program offers prescription drug coverage through Part D of Medicare to assist Medicare recipients in affording their drugs. Medicare Advantage and Medicare Part C are Medicare supplements. Also, Medicare-compliant private insurers manage these programs. All approved Part C plans must cover the same essential health benefits as Parts A and B and may also provide additional benefits like vision and dental insurance. Most Part C plans cover the cost of prescription drugs.

Medi-Cal: How it works

Medi-Cal is California’s Medicaid program. Medicaid gets federal and state funding. Medi-Cal is a single, comprehensive health insurance plan for low-income Californians.

A Medi-Cal application can be submitted either online or in person at the county Office of Human Services in California by citizens who need low- or no-cost health coverage. After receiving benefits, you can pay for recent medical expenditures. For instance, Medicare doesn’t pay for transportation to and from doctors’ appointments, but Medi-Cal does.

Medicare vs. Medicaid Disability Benefits

People who receive disability payments are eventually eligible for public health care coverage.

SSDI recipients get Medicare coverage (though not usually immediately). Medicaid recipients qualify for SSI (SSI). There is no waiting period for SSI recipients to qualify for Medicaid, but in some areas, they must apply for Medicaid on top of SSI.

Let’s look into Medicare vs. Medicaid disability benefits. Simply put, Medicare is not a poverty program like Medicaid. Medicare accepts all Medicare recipients regardless of income. You are eligible for Medicare if you have received either Disabled Adult Child’s Benefits, Widow’s or Widower’s Benefits, or Disability Insurance Benefits for at least 24 months. Medicare is preferable to Medicaid because it pays doctors more. Doctors are generally eager to accept Medicare patients. However, it does not kick in until after two years of receiving disability payments and does not often cover the cost of medication.

Medicare vs. Medicaid Dental Coverage

Medicare and Medicaid have been around for decades, yet many Americans still have misconceptions about who is eligible, the benefits they give, and the extent of their dental coverage. Understanding how these government programs may or may not help you is crucial since good oral hygiene can significantly impact your overall health.

What is the Medicaid program? Does Medicaid Pay for Dental Care?

Medicaid covers medical and dental costs for low income families, elderly, disabled people, and individuals.

Pregnant women, children under 21, adults over 65 who don’t qualify for Medicare, and disabled low-income people have assured enrollment.

Medicaid is a joint federal-state program. Therefore, eligibility requirements and benefits may differ greatly from one state to the next.

Early and routine screening and diagnosis treatment (EPSDT) criteria establish Medicaid eligibility for children and young adults. If you are under 21 and qualify for the program, it will cover all of the costs associated with the following services:

Screenings
Dental care for pain relief
Infections
Dental fillings

It also contributes to the cost of preventative measures and emergency procedures like:

Sealants
Cleanings
Crowns
Therapeutic procedures on the lungs (pulp treatment)
Treatments for misaligned teeth that aren’t purely aesthetic

What is and is not covered by the program for adults over the age of 21 varies greatly by location. Most American adults don’t get full dental care through their insurance.

Many of the most helpless among us lack the means to get the dental treatment they need. This is because many dentists in the United States do not recognize it. As per the Academy of General Dentistry, poor children have the most tooth decay in the U.S. Additionally, many adults who are in critical need of dental care go without treatment.

What’s Medicare? Does Medicare Cover Dental?

Medicare’s primary purpose is to assist the elderly and the severely disabled in meeting their healthcare costs. However, the program provides only minimal coverage for dental services. The law prohibits this program from paying for common medical services such as:

Cleanings
Fillings
Extractions
Dentures

The program only pays for dental care in extremely limited circumstances, such as:

In the event of a car crash, jaw reconstruction may be necessary.
If you have neoplastic jaw disease and must have teeth pulled before starting radiation therapy.

This situation occurs less frequently than one might think, leaving many beneficiaries concerned about how they will cover the exorbitant price of dental care out of pocket.

Social Security, Medicaid, and Medicare

Social Security

Wage earners, their spouses, former spouses, widows, widowers, and children are all eligible to receive benefits from the federal government’s Social Security program upon retirement, disability, or death. The worker’s employment records will determine whether or not they are qualified for program benefits. A recipient’s monthly Social Security payment is calculated using a formula that considers various criteria, including the recipient’s average wages and the number of years they contributed to the system.

Medicare

Medicare covers medical costs for the following groups:

1. Those over the age of 65;

2. Those under 65 with specific disabilities;

3. Handicapped kids of specific workers;

4. Those whose kidneys have failed permanently.

Parts A, B, C, and D of Medicare are subparts that help pay for different kinds of medical procedures.

Medicaid

Low-income and qualified people can get health insurance through the Medicaid program. People eligible for government aid, such as children, the elderly, and people with disabilities, can get coverage. Specifics in North Carolina may vary slightly from those in other states since, while based on federal legislation, implementation varies from state to state. This program receives funding from both the federal government and individual states. The Medicaid system offers many coverage options tailored to specific groups. Most of the nursing home coverage applications we process are for the elderly or people with special needs.

Can both Medicare and Medicaid cover me?

A person can be qualified for both Medicare and Medicaid and have coverage via both programs. Being “dual eligible” is a term used in the healthcare industry. In most cases, these people will have both Original Medicare and Medicaid coverage through Medicare Savings Programs like:

Qualified Medicare program (QMB)
- The SLMB Program is Medicare for low-income people.
- Disability Employment Program (QDWI)

These initiatives would supplement Medicare by reducing costs associated with premiums, deductibles, and coinsurance.

Even if you don’t have enough income to qualify for Medicaid, you may still be able to pay your Medicare Part A, B, and D deductibles. One can sign up for Medigap coverage, like Medicare Part F, provided by a private health insurance provider.

How do I know if I have Medicare?

If you’re curious about your Medicare coverage, you can do it in many ways:

Access your Medicare online account by signing in.
Access your Social Security online account by signing in.

Finally, you can see your enrollment status on Medicare’s website if you have the following information ready:

ZIP code
A Medicare number
Surname
Your birth date
The start of Medicare Part A

What is the lowermost and highest income that qualifies you for Medicaid?

Whether or not your salary is sufficient to be eligible for Medicaid depends on the state in which you now reside. Both are based on the Federal Poverty Level (FPL), a yearly HHS assessment of poverty.

Medicaid eligibility varies by state and by the recipient. Many states that have expanded Medicaid coverage require parents and single individuals to have incomes below 138% of the federal poverty level.

As of 2022, an individual’s federal poverty level is $13,590. The government further classifies your position about that sum as follows:

For premium tax credits in 2022, your household income must be 400% of the federal poverty standard.
Your household income is 100-400% of the federal poverty threshold (FPL). In all states, premium tax credits can help you purchase a Marketplace health insurance plan.
Your household income is below 150% of the FPL, but you don’t qualify for Medicaid or CHIP. You can enroll in or adjust Marketplace coverage during a Special Enrollment Period.
You have a low income and live in a state with extended Medicaid. In that instance, your income determines eligibility.
Your household income is below 100% of the poverty line (FPL). Income-based tax credits to help pay for a Marketplace health insurance plan or Medicaid may not be available.
Certain groups, such as the elderly, the disabled, pregnant women, and children, are typically exempt from the requirement that their income fall below a certain percentage threshold, which can vary depending on whether or not the individual is employed.

What is the lowermost income to qualify for Medicaid?

A lower eligibility requirement of 16 percent for a family of three has not extended its Medicaid coverage.

What is the highest income to qualify for Medicaid?

Medicare, or the Federal Health Insurance Program for People and Older Adults with Disabilities or Dialysis, is available to anyone who are 65 and over. Medicaid is a government health insurance program for those with low incomes.

Is Medicare the same as medical assistance?

Parting Thoughts!

After this holistic comparison of the Medicare vs. Medicaid plan, you should have a clear view of what to expect from each program. If you want to enroll in a health plan, get your customize quotes from New Medicare.

Reach out and accept Medicare plans today!