The Centers for Medicare and Medicaid Services (CMS), which were previously known as the Health Care Financing Administration (HCFA), manage all government health coverage programs. This includes Medicaid, Medicare and Health Insurance Exchanges. In fact, CMS has a coordination office that provides services and information to individuals who are eligible for both Medicare and Medicaid insurance programs. Therefore, you may engage with the CMS’ coordination office if you have Medicare Part B medical insurance and require supplemental insurance services through Medicaid or Medicaid supplements.
To learn more about Medicare vs. Medicaid and how eligibility is determined for both programs, continue reading. The following sections detail everything you need to know before you visit the CMS website to apply for coverage or search for specific insurance information. You will find answers to the question, “What is Medicare?” as well as find out how to apply and begin receiving your benefits.
Basics of Medicare
Many residents seeking affordable health insurance ask, “What is Medicare?” It is a health coverage options that consists of hospital insurance (Part A), medical insurance (Part B) and, in some cases, prescription drug coverage (Part D). Though each of these parts covers specific services that are necessary for many families, not all plans offer all parts. Some parts are optional, thus you can customize your coverage.
If you are new to Medicare, you can choose how you receive your coverage via the original plan or the Medicare Advantage (MA) option. Both plans offer both parts A and B coverage, but they operate differently.
With the original Medicare plan, each health service comes with an associated cost. However, beneficiaries can receive healthcare from any doctor, provider, hospital or medical facility enrolled in Medicare. You may add Part D drug coverage, but most prescriptions are already covered by this plan. With this policy, you may pay deductibles, coinsurance and copayments without annual limits and a monthly premium for Medicare Part B coverage.
Under MA, parts A, B and D are combined. Extra coverage like vision, hearing and dental might also be offered. They are managed by private companies approved by Medicare and, consequently, may charge different out-of-pocket costs and enforce different rules. MA plans include:
- Preferred Provider Organizations (PPOs).
- Special Needs Plans (SNPs).
- Health Maintenance Organizations (HMOs).
- Private Fee-For-Service (PFFS) plans.
You are advised to compare plans to determine which is the best option for you and your needs.
Note: Part D prescription drug insurance may only be added to certain Medicare plans, so check with your policy if prescription drug coverage is a desired service.
How are Medicare and Medicaid different?
When considering Medicare and Medicaid, know that Medicaid insurance provides coverage to more Americans. More than 70 million children, adults, seniors and persons with disabilities benefit from the program. However, similar to Medicare, the Medicaid program offers customizable benefit plans that can cover more individuals and families as well as more services.
Currently, each state has its own Medicaid office and program, so it is difficult to determine the type, amount and duration of benefits that may be available to eligible participants. Though, some mandatory benefits, such as hospital services, laboratory services and physician services, must be included in all Medicaid plans according to federal law. Still, it is important to note that Medicaid is a joint program that partners with the Children’s Health Insurance Program (CHIP) to ensure children receive the best care possible.
Medicare and Medicaid Eligibility
To be have Medicare eligibility, you must meet age, citizenship and other qualifying criteria. You may qualify for full Medicare benefits if you are:
- 65 years of age or older.
- A citizen of the United States or a resident with a permanent status.
- Eligible for Social Security and Medicare benefits on your own or through your spouse or eligible through contributions to Medicare through payroll taxes.
Conversely, Medicaid eligibility is determined by your financial status, citizenship and medical needs – not your age or work history. You may be eligible if:
- You earn a low income (at least 133 percent of the Federal Poverty Level)
- You have children or other dependents.
- Are a resident of the state in which you are requesting coverage.
- Are a citizen or qualified non-citizen of the United States.
- Demonstrate significant health needs that requires costly medical care and intervention.
Medicare, Medicaid Applications
If you meet Medicare eligibility requirements, you must submit your application during your initial enrollment period or the general enrollment period. You may apply for Medicare online, by phone, by mail or in person at your local Social Security office. Online applications are available to the following applicants:
- Applicants who are 64 years and 9 months of age
- Applicants who do not currently have Medicare coverage
- Applicants who do not yet want to start receiving social security benefits
- Applicants who are not currently earning social security retirement, disability or survivors benefits
Online applications take less than 10 minutes to complete and can be accessed on the CMS website or Social Security Administration (SSA)’s official website. Phone applications can be requested by calling the SSA. In-person applications require you to visit your local Social Security office and ask for a Medicare application. You may need to schedule an appointment to do so. To locate your closest Social Security office, enter your zip code into the SSA office locator.
Mail applications are also available but are reserved for Medicare Part B coverage only. You will need your Medicare number to complete this form. Sign the application and send it by mail to your nearest Social Security office during an enrollment period to finalize your application.
The Medicaid application process differs from the one required for Medicare coverage. You may only apply for Medicaid insurance using the online Health Insurance Marketplace during open enrollment each year. For more information about enrollment and the online Health Insurance Marketplace, contact your state’s Medicaid office.
Note: You may have to pay a late enrollment fee for Medicare Part B coverage if you enroll in it after Part A unless you qualify for a special enrollment period based on your current employment, health insurance and age.