Medicare and Medicaid were signed into law 36 years ago to protect older and poorer Americans against the high cost of health care. Ironically, it is the high cost of providing health care through these programs that now threatens federal and state budgets, leading to calls for Medicare and Medicaid reform. Although these programs are often lumped together, they function quite differently. Here is a look at the coverage each provides.
What is Medicare?
Medicare is a health insurance program funded and run by the federal government that guarantees health coverage to older Americans. Medicare is not income-based. People who have paid Medicare taxes on their earnings are automatically eligible at age 65, but some people with disabilities qualify for Medicare coverage earlier than age 65, and people with end-stage renal disease qualify at any age.
Medicare offers three main types of coverage. Part A covers inpatient hospital care, as well as short-term skilled nursing care, hospice care and home health care under certain conditions. Part B covers medical services such as doctor's visits, outpatient care and laboratory tests. Part D covers prescription drugs. If you or your spouse has paid Medicare taxes while working, you generally will not pay a premium for Medicare Part A coverage, but you will pay a premium if you want to enroll in Part B or in some, but not all, Part D plans. You will also need to pay certain out-of-pocket costs such as deductibles, co-payments or coinsurance costs, depending on the types of coverage you have.
What is Medicaid?
Medicaid is a health insurance program funded by the federal government and state governments to provide coverage to Americans of all ages who have low incomes and no health insurance. States administer their own Medicaid programs under federal guidelines. They must cover individuals on public assistance, but they may also opt to cover other groups and establish eligibility requirements. Children, families, people with disabilities and older individuals may all receive Medicaid.
If you are eligible for Medicaid, you may have to pay a small co-payment when receiving medical services, but most of your health-care costs will be covered.
Can you be eligible for both Medicare and Medicaid?
Yes – if you are eligible for both programs, you are known as a "dual eligible" beneficiary. Generally, individuals who are eligible for both programs are older or disabled (or both) and need help paying their Medicare costs because they have very low incomes. Medicaid covers premiums, deductibles, co-payments, coinsurance and other Medicare costs and provides some health benefits that Medicare does not. Individuals in nursing homes are often dual eligible beneficiaries, and that is partly behind the misconception that Medicare pays for nursing home or other long-term care (it does not – please see paragraph following the table below); instead, Medicaid is the primary payer of nursing home bills. Because many older individuals cannot afford the high cost of nursing home care and exhaust their savings, they eventually become eligible for Medicaid.
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Medicare
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Medicaid
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Primarily age-based; individuals age 65 and older qualify, along with some individuals with disabilities
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Primarily means-based; individuals of any age with low incomes who meet eligibility requirements may qualify
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The federal government runs Medicare, and the program is the same for all Americans
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State governments run programs under federal guidelines, so programs vary from state to state
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Financing comes from federal funds; partly financed through payroll taxes and premiums
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Financing comes from federal, state and local revenue
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Medicare Part A provides coverage for hospital stays; Medicare Part B covers the cost of doctor's bills, laboratory costs and some outpatient costs; Medicare Part D covers some prescription drug costs
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Broader coverage of health costs than Medicare, including inpatient and outpatient care, prescription drugs, laboratory costs, family planning and nursing home care (types of coverage may vary from state to state)
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Medicare beneficiaries may pay deductibles, co-payments, coinsurance costs and premiums
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Medicaid generally pays all approved charges, though a small deductible or co-payment may be required
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Medicaid, not Medicare, is the primary payer of nursing home care in the United States. Although Medicare pays for short-term skilled nursing or rehabilitative care in a skilled nursing facility, it does not pay for extended care in a nursing home or for other custodial long-term care. Custodial care refers to help with daily activities such as eating, bathing, dressing and using the bathroom. Some individuals need both short-term and long-term care; for example, someone who has suffered a stroke may receive rehabilitation services in a skilled nursing facility, but may later be admitted to a nursing home in order to receive custodial long-term care services.
For more information, visit the Centers for Medicare & Medicaid Services website at www.cms.gov.