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Medicare vs. Medicaid

Generally speaking, the most notable difference between Medicare and Medicaid is eligibility. To be eligible for Medicare, you must either:

  • Be a U.S. Citizen and Be 65 Years Old or Older
  • Have End-Stage Renal Disease (ESRD) or Lou Gehrig’s Disease
  • Be Receiving/Can Receive Social Security or Railroad Retirement Benefits
  • Be Under 65 and Have Received Certain Disability Benefits from the RRB for at Least 24 Months
  • Be Under 65 and Have Received Disability Benefits from Social Security for 24 Months or More

Medicare eligibility, then, is largely based on age, health, and/or work history. Your Medicaid eligibility, on the other hand, is largely based on financial need. 

Modified Adjusted Gross Income (MAGI) is used to determine your financial eligibility for Medicaid. You are exempt from this consideration based on disability (including blindness) and age (65 or older)—if you fall under these categories, your Medicaid eligibility is based on Supplemental Security Income (SSI) rather than MAGI.

Medicare and Medicaid Together

These requirements allow people to receive both Medicare and Medicaid at once. Both plans will put money towards your healthcare costs and greatly reduce your out-of-pocket costs.

Medicare will put money towards costs first, then Medicaid will pay its remaining share. The amount of money Medicaid will put towards costs is dependent on your coverage status. 

If you are fully eligible for both forms of coverage, all of your costs will be covered. If you are partially dually eligible, you may still have some out-of-pocket costs. There are different dual-eligibility programs that determine this:

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Medicare and Medicaid Together

These requirements allow people to receive both Medicare and Medicaid at once. Both plans will put money towards your healthcare costs and greatly reduce your out-of-pocket costs.

Medicare will put money towards costs first, then Medicaid will pay its remaining share. The amount of money Medicaid will put towards costs is dependent on your coverage status. 

If you are fully eligible for both forms of coverage, all of your costs will be covered. If you are partially dually eligible, you may still have some out-of-pocket costs. There are different dual-eligibility programs that determine this:

  • QMB program: This program supports the payment of Medicare Part A and B premiums for individuals with an income 100% on the Federal Poverty Level (FPL). QMB Plus includes the benefits of QMB as well as full Medicaid benefits.
  • Specified Low-Income Medicare Beneficiary (SLMB) program: Pays the Part B premiums for individuals with an income >100 percent FPL but <120 FPL. SLMB Plus includes benefits from the SLMB program as well as full Medicaid benefits.
  • Qualified Disabled Working Individual (QDWI) program: If you return to work and lose your Medicare Part A coverage, you can buy back these benefits if you have an income up to 200% of the FPL.
  • Qualifying Individual (QI) program: Receives Medicare Part A benefits and has an income 120% of the FPL <135% of the FPL with no cap on the money given annually.
  • Pharmacy duals: Covers Medicare Part D premiums, deductibles, and other cost sharing for prescription drugs.
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MedicareMisty’s team of dedicated agents are here for you. We want to help match you with the coverage you need. If you would like a free quote, give us a call at (423)240-0794.