Medicare and Medicaid: What's the Difference?

Medicare and Medicaid coverage explained.

Medicare and Medicaid are very different. Medicaid is a federal program for low-income, financially needy people, set up by the federal government and administered differently in each state. (This program is called Medi-Cal in California.)

Medicare was created to deal with the high medical costs that older citizens face relative to the rest of the population especially troublesome given their reduced earning power. However, eligibility for Medicare is not tied to individual need. Rather, it is an entitlement program; you are entitled to it because you or your spouse paid for it through Social Security taxes.

Although you may qualify for and receive coverage from both Medicare and Medicaid, you must meet separate eligibility requirements for each program; being eligible for one program does not necessarily mean you are eligible for the other. If you qualify for both, Medicaid will pay for most Medicare Part A and B premiums, deductibles, and copayments.

The information below provides the basics of each program.

Medicare

• Who is Eligible: Medicare covers almost everyone 65 or older, certain people on Social Security disability, and some people with permanent kidney failure.
• Who Administers the Program: Medicare is a federal program whose rules are the same all over the country. Medicare information is available at your Social Security office.
• Coverage Provided:
  • Medicare hospital insurance (Part A) provides basic coverage for hospital stays and posthospital nursing facility and home health care.
  • Medicare medical insurance (Part B) pays most basic doctor and laboratory costs, and some outpatient medical services, including medical equipment and supplies, home health care, and physical therapy.
  • Medicare prescription drug coverage (Part D) pays some of the costs of prescription medications.
• Costs to Consumer: You must pay a yearly deductible for both Medicare Part A and Part B, and make hefty copayments for extended hospital stays. Under Part B, you must pay the 20% of doctors' bills Medicare does not pay, and sometimes up to 15% more. Part B also charges a monthly premium. Under Part D, you must pay a monthly premium, a deductible, copayments, and all of your prescription drug costs over a certain yearly amount and up to a ceiling amount, unless you qualify for a low-income subsidy.

Medicaid

• Who is Eligible: Medicaid covers low-income and financially needy people, including those over 65 who are also on Medicare.
• Who Administers the Program: Medicaid is administered by the 50 states; rules differ in each state. Medicaid information is available at your local county social services, welfare, or department of human services office.
• Coverage Provided:
  • Medicaid provides comprehensive inpatient and outpatient health care coverage, including many services and costs Medicare does not cover, most notably, prescription drugs, diagnostic and preventive care, and eyeglasses. The amount of coverage, however, varies from state to state.
  • Medicaid can pay Medicare deductibles and 20% portion of charges not paid by Medicare. Medicaid can also pay the Medicare premium.
• Costs to Consumer: In some states, Medicaid charges consumers small amounts for certain services.

Further Resources

For more information on what Medicare doesn't cover, see Nolo's article Medigap: Covering the Gaps in Medicare.

To learn more about health care options in your retirement years, get Social Security, Medicare, and Government Pensions, by Joseph Matthews and Dorothy Matthews Berman (Nolo).