Who Is Eligible for Medicare and Medicaid?

Medicare and Medicaid are two government-sponsored programs that help Americans access more affordable health care. However, what these programs provide — and who is eligible for Medicare and Medicaid in the first place — can frequently get confused.

That's why it's critical to understand these programs and their eligibility requirements so you can determine your best path forward when enrolling in Medicare or Medicaid.

What Is Medicare?

Medicare is a program meant to provide medical coverage for those age 65 and older. Eligibility for Medicare is primarily based on age; income plays no role in determining if you qualify.

Medicare coverage divides into four parts:

  • Part A covers emergency and in-patient hospital stays and procedures.
  • Part B covers doctor visits and other medically necessary services and equipment.
  • Part C is also known as Medicare Advantage; these plans typically offer similar coverage to Parts A and B, but they're run through federally approved private insurers.
  • Part D provides prescription drug coverage.

Parts A and B are known as Original Medicare. Medicare enrollees pay a monthly premium based on the plan they choose as well as their income to get coverage.

Who Is Eligible for Medicare?

Citizens and permanent residents who are 65 and older are eligible for Medicare coverage for a seven-month eligibility period — your birthday month and the three months before and after.

You're automatically enrolled in Medicare Parts A and B if you receive Social Security benefits. If you aren't claiming Social Security benefits yet but have contributed to Medicare through payroll taxes for at least 10 years, however, you may also enroll in Medicare.

How To Enroll in Medicare

The Social Security Administration (SSA) administers Medicare. If you are not already collecting Social Security benefits, the SSA recommends signing up for Medicare three months before you turn 65. If you miss the enrollment period, you may have to pay higher premiums.

Medicare also runs yearly open enrollment periods. During this period every year, you can choose to continue with Original Medicare, sign up for Medicare Part D or explore Medicare Advantage and Medigap plans.

To learn more about Medicare qualifications and eligibility and enroll, visit Medicare.gov.

What Is Medicaid?

Medicaid is a federal and state partnership assistance program aimed at helping low-income Americans access health care at a low or no cost. Medicaid qualifications are primarily based on your income, and the program does not have set age restrictions. Medicaid provides assistance to pregnant mothers and children as well as those with low income and disabilities, irrespective of age.

The federal government sets regulations for Medicaid, including qualifying income levels and other considerations for eligibility. However, each state administers the program itself, which means that benefits and the potential pool of enrollees may vary widely across the country. Some states have expanded Medicaid to offer assistance to more people, so make sure you check the specific qualifications for the state where you live.

Who Is Eligible for Medicaid?

Medicaid has very strict eligibility qualifications, and enrollment is determined based on financial need. Currently, U.S. citizens and permanent residents who have incomes up to 138% of the federal poverty line may qualify for Medicaid coverage in participating states.

In some states, to be eligible for Medicaid, you must meet income limits and also have liquid assets below a specified amount. Also, keep in mind that it is possible to qualify for and enroll in Medicare and Medicaid simultaneously.

How To Enroll in Medicaid

If you qualify for Medicaid, you'll need to apply for the program. You can do that through the health insurance marketplace on healthcare.gov or by contacting your local Medicaid office.

Before you apply, make sure you have your documentation in order. Medicaid will typically ask for proof of citizenship and residence, income and assets, medical history and copies of current bills.

What To Do If You're Denied Coverage

Not everyone is automatically approved for Medicare and Medicaid enrollment. If you receive a denial letter for Medicare, it may be based on whether you've exhausted your coverage. Each state has an appeal process; read the letter carefully to find instructions on how to request an appeal, and contact your local Medicaid office for next steps.

As your income or health care needs change, it's important to learn who is eligible for Medicare and Medicaid so that you can choose the best option for your needs.

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