When it comes to healthcare coverage in the United States, two government programs often come up: Medicare and Medicaid. While their names sound similar, they serve very different purposes and eligibility groups. Knowing which one you qualify for — and which one best meets your needs — can save you time, stress, and potentially thousands of dollars in healthcare costs.
Understanding the Basics
What Is Medicare?
Medicare is a federal health insurance program primarily for:
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Adults 65 and older
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Certain younger individuals with disabilities
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People of any age with End-Stage Renal Disease (ESRD) or ALS
Medicare has several parts:
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Part A: Hospital coverage
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Part B: Outpatient and doctor visits
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Part C (Medicare Advantage): Private plans that combine Parts A and B, often with drug coverage
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Part D: Prescription drug coverage
Medicare is not based on income, though higher earners may pay more for certain parts.
What Is Medicaid?
Medicaid is a joint federal and state program that provides health coverage for:
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People with low income
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Pregnant women
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Children
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Seniors who also have low income
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People with disabilities who meet financial requirements
Because Medicaid is run by states under federal guidelines, eligibility rules and covered benefits vary depending on where you live.
Key Factors to Determine Which You Need
1. Age
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65 or older: You may qualify for Medicare, regardless of income.
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Under 65: You could qualify for Medicare only if you have a qualifying disability or medical condition.
2. Income and Financial Resources
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Low income or limited assets: Medicaid may be available to you.
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Above your state’s income threshold: You may not qualify for Medicaid, but Medicare could still apply if you’re 65+ or disabled.
3. Disability Status
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If you receive Social Security Disability Insurance (SSDI) for at least 24 months, you’ll typically qualify for Medicare.
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Medicaid may be an option if your disability limits your income and assets.
4. Healthcare Needs
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If you need long-term care in a nursing home, Medicare covers it only for short stays (up to 100 days). Medicaid, however, may cover long-term care if you meet financial requirements.
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If you require extensive prescription coverage, compare Medicare Part D with your state’s Medicaid program.
5. Dual Eligibility
Some people qualify for both Medicare and Medicaid.
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Medicare serves as the primary insurance.
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Medicaid helps cover nursing home care, Medicare premiums, deductibles, and services Medicare may not fully pay for, such as long-term nursing care.
Steps to Take if You’re Unsure
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Check Your Age and Disability Status
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If 65+, Medicare is almost always an option.
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If under 65, review disability criteria.
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Review Your Income and Assets
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Each state has its own Medicaid income and asset limits. Check with your state’s Medicaid office.
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Use Eligibility Tools
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Visit Medicare.gov for Medicare eligibility.
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Visit Medicaid.gov or your state’s Medicaid website for local requirements.
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Talk to a Benefits Counselor
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Free counseling is available through your local State Health Insurance Assistance Program (SHIP).
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Bottom Line
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If you’re 65 or older (or younger with a disability), you likely qualify for Medicare.
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If you’re low-income, regardless of age, you may qualify for Medicaid.
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If you meet both sets of requirements, you could be eligible for both, which can maximize your healthcare coverage.
Understanding the differences — and checking your personal eligibility — is the best way to ensure you get the healthcare coverage you need.