What is Medicare?
Medicare is a federal health insurance program primarily designed for individuals aged 65 and older, but it also extends to certain younger individuals who meet specific criteria. To qualify, applicants must be citizens or permanent residents of the United States and have paid Medicare taxes for a requisite period, generally 10 years. I
Medicare consists of several parts, each serving a distinct purpose in the overall healthcare framework. Part A covers inpatient hospital stays and some home health care, while Part B focuses on outpatient services and preventive care. Part C allows beneficiaries to access their benefits through private insurance plans that may offer extra services. Lastly, Part D offers prescription drug coverage, helping beneficiaries afford necessary medications.
What is Medicaid?
Medicaid is a collaborative program between the federal and state governments designed to assist individuals with limited income and resources in covering their medical expenses. While the federal government sets overarching guidelines, each state administers its own Medicaid program, leading to variations in eligibility criteria and available benefits across different states. Unlike Medicare, Medicaid provides coverage for services such as nursing home care and personal care assistance.
Who is eligible for both Medicare & Medicaid
Individuals who qualify for both Medicare and Medicaid are referred to as “dual eligibles” or sometimes as Medicare-Medicaid enrollees. To be classified as dually eligible, individuals must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). Instead of Original Medicare (Parts A and B), individuals can choose Medicare Part C. While Original Medicare is administered by the federal government, plans are run by private insurance companies approved by Medicare. Through Medicare Advantage, participants receive coverage from Part A, Part B, and often Part D.
Additionally, to qualify as dual eligible, individuals must also be enrolled in either full coverage Medicaid or one of Medicaid’s Medicare Savings Programs (MSPs). Full coverage Medicaid includes benefits for doctor visits, hospital services (both inpatient and outpatient), laboratory services, and x-rays. Additionally, Medicaid covers nursing home care and often provides limited personal care assistance at home.
What is the difference between Medicare and Medicaid for the elderly ?
Medicare and Medicaid serve different purposes for the elderly. Medicare typically requires enrollees to pay premiums and out-of-pocket costs, while Medicaid focuses on reducing expenses for low-income individuals. Additionally, Medicaid is especially advantageous for seniors who need long-term care services, such as nursing homes or assisted living, which are generally not covered.
How can I qualify for Medicare or Medicaid based on a disability?
If you are receiving Supplemental Security Disability Income (SSDI), you may qualify for either Medicaid, Medicare, or both. Medicare is mainly designed for individuals aged 65 and older. However, if you are younger and have a disability, you can qualify for Medicare if you have been approved for Social Security Disability Insurance (SSDI). Typically, there is a 24-month waiting period before your coverage starts, but there are two exceptions to this waiting period:
- If you have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, you will be enrolled in Medicare in the first month you start receiving SSDI.
- If you have end-stage renal disease (ESRD), your Medicare coverage usually begins after you have undergone three months of dialysis treatment.
There are additional ways to qualify for Medicaid related to a disability, but unlike Medicare, these options are tied to your overall income. These include:
- Medically needy: If you have a disability but your income exceeds the threshold, you may still qualify if your medical expenses push your income above the approved limit.
- Special income level: If you or a family member is residing in a healthcare facility due to a medical condition, age, or disability, your state may offer Medicaid coverage even if your income surpasses the coverage limit. This can also apply to individuals receiving home and community-based services instead of living in a healthcare facility.
- Working individuals with disabilities: States are required to provide coverage for certain individuals with disabilities whose income would typically disqualify them. Additionally, some states may allow other working individuals with disabilities to purchase Medicaid coverage.
Additionally, some states do not permit eligibility for Medicaid based on disability, which can complicate the process for many individuals. It’s important to note that these regulations can change annually, and each state establishes its own income limits for Medicaid eligibility according to the federal poverty level. To ensure you make well-informed decisions regarding your enrollment, we highly recommend scheduling a free consultation with our licensed health insurance agents, who can guide you through the specific requirements of your state.
Resources
U.S. Department of Health and Human Services. “What Is the Difference between Medicare and Medicaid?” HHS.gov, U.S. Department of Health and Human Services, 2022, www.hhs.gov/answers/medicare-and-medicaid/what-is-the-difference-between-medicare-medicaid/index.html.
Dual Eligibility for Medicare and Medicaid: How It Works. www.medicaidplanningassistance.org/dual-eligibility-medicare-medicaid/.
Sharon, Alina. “Qualifying for Medicare vs. Medicaid with a Disability.” Healthline, Healthline Media, 3 Mar. 2025, www.healthline.com/health/medicare/medicare-vs-medicaid-disability#eligibility-differences. Accessed 23 July 2025.