It’s one of the most common questions we hear:

“What’s the difference between Medicare and Medicaid?”

Both programs help people pay for healthcare, and both are run (at least in part) by the government — so it’s easy to mix them up. But the truth is, Medicare and Medicaid serve different groups of people, have different eligibility rules, and offer different kinds of benefits.

At MediHealth Options, we help individuals understand how these programs work — especially if they qualify for one or both. If you’re unsure which program applies to you, or how to maximize your coverage, this guide is for you.

What Is Medicare?

Medicare is a federal health insurance program for people:

• 65 or older
• Under 65 with certain disabilities
• Of any age with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s Disease)

It’s funded and administered by the federal government — specifically the Centers for Medicare & Medicaid Services (CMS) — and is generally the same across all states.

You don’t have to be low-income to qualify. Medicare is based primarily on age and disability status, not financial need.

At MediHealth Options, we help clients navigate the different parts of Medicare, understand their coverage options, and avoid common mistakes during enrollment.

What Is Medicaid?

Medicaid is a state and federally funded health program designed for low-income individuals and families. Unlike Medicare, Medicaid is based on financial need and is run jointly by your state and the federal government.

Each state sets its own rules for:

• Income limits
• Asset thresholds
• Eligibility groups
• Covered services

Some people may qualify for Medicaid regardless of age, including:

• Children
• Pregnant women
• Low-income adults
• Seniors with limited income
• People with disabilities

Because Medicaid rules vary widely by state, it’s important to understand what’s available where you live — especially if you’re thinking about long-term care or dual eligibility. MediHealth Options works with many clients who are eligible for both Medicare and Medicaid, helping them get the most out of their combined benefits.

Who Qualifies for Medicare?

Medicare eligibility is not based on income. You qualify if you meet one of the following conditions:

✅ Age-Based Eligibility

• You’re 65 or older
• You’re a U.S. citizen or permanent legal resident living in the U.S. for at least 5 years
• You or your spouse paid Medicare taxes for at least 10 years

✅ Disability-Based Eligibility

• You’ve been receiving Social Security Disability Insurance (SSDI) for at least 24 months
• You have ALS (automatic Medicare eligibility begins the same month you start SSDI)
• You have End-Stage Renal Disease (ESRD) and meet specific treatment criteria

Enrollment can happen automatically or manually, depending on your situation. At MediHealth Options, we help individuals determine when and how to enroll — and what type of plan fits best once they’re eligible.

Who Qualifies for Medicaid?

Medicaid eligibility is income-based and determined by each state. However, most states provide coverage for:

• Individuals and families below a certain income threshold
• People with disabilities and limited resources
• Children, pregnant women, and seniors with low income

In states that expanded Medicaid under the Affordable Care Act (ACA), adults under 65 with incomes up to 138% of the federal poverty level are eligible.

General Income Guidelines (subject to state-specific rules):

• Single adult: ~$20,000 per year
• Family of four: ~$41,000 per year

Each state has its own guidelines, which can include asset limits, residency requirements, and citizenship status.

If you think you might qualify for both Medicaid and Medicare — known as dual eligibility — MediHealth Options can help determine your status and explore plan options designed for people with both types of coverage.

What Does Medicare Cover?

Medicare is divided into different “parts,” each covering specific services:

🏥 Part A (Hospital Insurance)

• Inpatient hospital stays
• Skilled nursing facility care
• Hospice
• Some home health care

Cost: Usually premium-free if you or your spouse worked and paid Medicare taxes for 10+ years

🩺 Part B (Medical Insurance)

• Doctor’s visits
• Outpatient care
• Preventive services (screenings, vaccines)
• Durable medical equipment
• Mental health services

Cost: Monthly premium (in 2025, standard is ~$174.70/month)

💊 Part D (Prescription Drug Coverage)

• Covers outpatient prescription drugs
• Offered through private plans approved by Medicare

Cost: Varies by plan, premiums and copays apply

🌐 Part C (Medicare Advantage)

• Alternative to Original Medicare (Parts A and B)
• Offered by private insurance companies
• Often includes Part D + extras like dental, vision, hearing

➕ Medigap (Medicare Supplement)

• Helps pay out-of-pocket costs not covered by Original Medicare
• Available to those enrolled in Original Medicare (not Advantage)

At MediHealth Options, we help clients compare all of these options and choose the right mix of coverage based on their budget and health needs.

What Does Medicaid Cover?

Medicaid covers a wide range of healthcare services, but the exact benefits vary by state. Federal guidelines require Medicaid to cover:

• Doctor visits
• Hospital care
• Nursing home care
• Home health services
• Lab tests and X-rays
• Family planning
• Pediatric care and immunizations

States May Also Cover:

• Dental care
• Vision and hearing services
• Non-emergency medical transportation
• Prescription drugs
• Behavioral health and substance abuse treatment

Because Medicaid is administered at the state level, your benefits, provider networks, and coverage levels may be significantly different depending on where you live. If you're unsure what Medicaid covers in your state, MediHealth Options can help you make sense of it — especially if you're dually eligible.

Can You Have Both Medicare and Medicaid?

Yes — this is called dual eligibility. If you qualify for Medicare based on age or disability, and for Medicaid based on income, you may be eligible for both programs at once.

This can be incredibly beneficial. Here’s how it works:

Dual-Eligible Individuals May Receive:

• Help paying Medicare premiums, deductibles, and copays
• Access to a Medicare Advantage Special Needs Plan (D-SNP) tailored for dual-eligibles
• Broader benefits, such as dental, vision, hearing, transportation, and more

There are different levels of dual eligibility depending on your income and state rules. At MediHealth Options, we help determine your eligibility and connect you with plans designed specifically for dual coverage.

Common Questions About Medicare and Medicaid

❓ Can Medicaid help pay my Medicare premiums?

Yes — Medicaid can help pay for Part B premiums, Part D premiums, and other out-of-pocket costs for eligible individuals. This is especially common among dual-eligible individuals.

❓ Do I have to apply for Medicare and Medicaid separately?

Yes — you apply for Medicare through the Social Security Administration and for Medicaid through your state’s Medicaid office. The processes are separate but can overlap for dual-eligible individuals.

❓ What happens if my income changes?

Medicaid eligibility may change if your income rises. You may lose coverage or move into a different eligibility tier. Medicare eligibility, however, is generally unaffected by income changes (except for premium adjustments).

❓ Can MediHealth Options help with both Medicare and Medicaid?

Yes — MediHealth Options helps clients understand their Medicare options, and if you’re dual-eligible, we’ll guide you toward plans that maximize your combined benefits.

How MediHealth Options Helps You Navigate Medicare and Medicaid

Understanding the difference between Medicare and Medicaid is one thing. Figuring out which one (or both) you qualify for — and what plan makes the most sense — is another.

At MediHealth Options, we provide:

• One-on-one Medicare plan guidance
• Help identifying if you’re dual-eligible
• Access to Medicare Advantage Special Needs Plans (D-SNPs)
• Comparisons of coverage, costs, and provider networks
• Continued support year after year

Whether you're new to Medicare, exploring Medicaid for the first time, or managing both, we’re here to simplify the process and ensure you’re getting the most out of your coverage.

Conclusion: What Is the Difference Between Medicare and Medicaid?

Let’s recap:

• Medicare is primarily for older adults and people with disabilities, regardless of income.
• Medicaid is for low-income individuals and families, and eligibility rules vary by state.
• You can qualify for both — and doing so may significantly reduce your healthcare costs.
• Choosing the right plan takes time, research, and understanding — and that’s where we come in.

If you’re confused about your eligibility or want to explore plans that match your healthcare needs, let us help.

📞 Ready to Explore Your Medicare or Medicaid Options?

Visit MediHealth Options to get personalized help understanding Medicare, Medicaid, and how to choose the right plan — especially if you may qualify for both.

You don’t have to figure it out alone. We’re here to make the process clear, honest, and manageable.