Medicare is a federal health insurance program open to Americans aged 65 and older, and those with specific disabilities who are under the age of 65. Medicaid, a combined state and federal program, is a state-specific health insurance program for low-income individuals with limited financial means, regardless of their age.
Medicare, generally speaking, offers the same benefits to all eligible participants. However, coverage is divided into Medicare Part A, Part B, and Part D. Medicare Part A is for hospice care, skilled nursing facility care, and inpatient hospital care. Medicare Part B is for outpatient care, durable medical equipment, and home health care. Part D is for prescription coverage. Not all persons will elect to have coverage in all three areas. In addition, some persons choose to get their Medicare benefits via Medicare Advantage plans, also called Medicare Part C. These plans are available via private insurance companies and include the same benefits as Medicare Part A and Part B, as well as some additional ones, such as dental, vision, and hearing. Many Medicare Advantage plans also include Medicare Part D.
Medicaid is more comprehensive in its coverage, but the benefits are specific to the age group. Children have different eligibility requirements and receive different benefits from low-income adults and from elderly or disabled persons.
In the context of long term care for the elderly, Medicare’s benefits are very limited. Medicare does not pay for personal care (also known as custodial care or non-medical care). Medicare will pay for a very limited number of days (no more than 100 days following hospitalization for a minimum of 3 days) of skilled nursing (also referred to as nursing home care). Medicare will also pay for some home health care, provided it is medical in nature. Starting in 2019, some Medicare Advantage plans started offering long term care benefits. These services and supports are plan specific. But they may include:
Medicaid, being state run, has different benefits in each state. Generally speaking, Medicaid pays for nursing home care. Through home and community based services waiver programs it may also pay for:
To avoid confusion, it is worth noting that Medicaid is referred to by different names in different states. For example, in California it is called Medi-Cal, in Kansas it is called KanCare, and in Massachusetts it is called MassHealth.
|Eligibility in 2019||Medicare||Medicaid|
|Age Limit||65 and older||No age limit|
|Income Limit||No income limit||Approximately $2,313 / month*|
|Asset Limit||No asset limit||Approximately $2,000**|
|Health Restrictions||None||Some depending on program / waiver|
Yes, Medicare and Medicaid are not mutually exclusive programs. Persons who are eligible for both are referred to as having Dual Eligibility, Dual Eligibles, or often simply “Duals”. Medicare is the first payer of covered benefits, while Medicaid is the secondary payer. Typically, Medicaid will pay for Medicare premiums and co-payments for dual eligibles. In fact, many states have special programs intended to make it easier for seniors to manage their dual eligibility status as it can be confusing to know where to turn for what services. This is generally in the form of managed care.