Medicare is federal health insurance mostly for people 65 and older (or with certain disabilities), and it doesn’t check your income. Medicaid is a joint federal-state program based on income and assets, and eligibility rules vary by where you live. If you qualify for both — known as being “dual eligible” — Medicaid can pick up many of the costs Medicare leaves behind, including premiums, copays, and long-term care.
The Core Difference in One Sentence
Medicare is insurance you earn through work history and age; Medicaid is assistance based on financial need. That distinction drives everything else — who’s eligible, what’s covered, and what you pay out of pocket.
What Medicare Is and Who Qualifies
Medicare is run entirely by the federal government through the Centers for Medicare & Medicaid Services (CMS). You generally qualify if you’re:
- 65 or older and a U.S. citizen or legal resident who’s lived here at least 5 years
- Under 65 but receiving Social Security Disability Insurance (SSDI) for 24 months
- Diagnosed with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s disease), regardless of age
Medicare has four parts:
- Part A (hospital insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care. Most people get this premium-free because they (or a spouse) paid Medicare payroll taxes for at least 10 years (40 quarters).
- Part B (medical insurance): Covers doctor visits, outpatient care, preventive services, and durable medical equipment. For 2026, the standard Part B premium is $202.90/month (up from $185 in 2025), with a $283 annual deductible, per CMS.gov. Higher-income enrollees pay more under IRMAA surcharges.
- Part C (Medicare Advantage): Private insurance plans approved by Medicare that bundle Parts A and B, often with drug coverage and extras like dental or vision.
- Part D (prescription drug coverage): Optional drug plans offered by private insurers.
Medicare isn’t free. You pay premiums (for Part B and often Part D), deductibles, and 20% coinsurance on most Part B services with no annual out-of-pocket cap unless you have a Medicare Advantage plan or supplemental coverage (Medigap).
What Medicaid Is and Who Qualifies
Medicaid is jointly funded by the federal government and each state, and states run their own programs within federal guidelines. That means benefits, income limits, and even the program’s name can differ — it’s called Medi-Cal in California, MassHealth in Massachusetts, and so on.
Eligibility generally depends on:
- Income, measured against the Federal Poverty Level (FPL). In states that expanded Medicaid under the Affordable Care Act, adults can qualify with household income up to 138% of the FPL. For 2026 guidelines, check the annually updated FPL tables at HHS.gov, since the dollar thresholds shift each January.
- Household size and category — pregnant women, children, people with disabilities, and low-income seniors often have different (usually higher) income limits than childless adults.
- State residency and, in most cases, citizenship or qualifying immigration status.
Unlike Medicare, Medicaid usually has little to no premium, and copays are typically small or waived entirely, especially for children and pregnant women. Medicaid also covers services Medicare doesn’t touch, most importantly long-term nursing home care and personal care assistance.
Medicare vs. Medicaid: Side-by-Side Comparison
| Feature | Medicare | Medicaid |
|---|---|---|
| Administered by | Federal government (CMS) | State + federal, rules vary by state |
| Based on | Age (65+) or disability | Income and assets |
| Cost to enrollee | Premiums, deductibles, coinsurance | Usually little to no cost |
| Covers long-term nursing home care | No (only short skilled nursing stays) | Yes, often the primary payer |
| Covers routine dental/vision | Rarely (some Medicare Advantage plans do) | Often, especially for children |
| Enrollment period | Set windows (Initial, Open, Special) | Rolling — apply anytime |
| Where to apply | SSA.gov or Social Security office | Your state Medicaid agency or Healthcare.gov |
What Each Program Actually Covers
Medicare’s strength is acute medical care: hospital stays, surgeries, doctor visits, cancer treatment, and prescription drugs (through Part D or Medicare Advantage). What it doesn’t cover well is custodial care — help with bathing, dressing, or eating that doesn’t require a nurse or doctor. Medicare Part A will pay for a skilled nursing facility stay, but only up to 100 days per benefit period, and only after a qualifying 3-day hospital stay, and only for skilled (not custodial) care.
Medicaid’s strength is exactly that gap: long-term custodial care. According to Medicaid.gov, Medicaid is the largest payer of nursing home and long-term care services in the country. It also covers things Medicare mostly skips — non-emergency medical transportation, personal care attendants, and in many states, dental and vision for adults.
Can You Have Both? Understanding Dual Eligibility
Yes. Nearly 12 million Americans are “dual eligible,” meaning they qualify for both programs at once, according to CMS. This typically happens when someone is 65+ or disabled (qualifying for Medicare) and also has low income and limited assets (qualifying for Medicaid).
When you’re dual eligible, the two programs work together instead of duplicating benefits:
- Medicare pays first for Medicare-covered services (hospital, doctor visits, drugs).
- Medicaid pays second, covering Medicare’s premiums, deductibles, and coinsurance, plus services Medicare doesn’t cover at all, like long-term care.
There are also partial dual-eligibility categories called Medicare Savings Programs (MSPs), run through Medicaid, that help pay Medicare costs even if you don’t qualify for full Medicaid benefits. These include:
- Qualified Medicare Beneficiary (QMB): Pays Part A and B premiums, deductibles, and coinsurance.
- Specified Low-Income Medicare Beneficiary (SLMB): Pays Part B premium only.
- Qualifying Individual (QI): Also pays Part B premium, for those with slightly higher income than SLMB.
Income limits for MSPs are tied to the FPL and adjusted yearly — for exact 2026 thresholds in your state, contact your State Health Insurance Assistance Program (SHIP) or your state Medicaid office, since some states set limits higher than the federal minimum.
If you’re dual eligible, you may also qualify for Extra Help, the federal program that lowers Medicare Part D drug costs. Full-benefit dual eligibles are automatically enrolled in Extra Help — you don’t need to apply separately, according to SSA.gov.
How to Apply
For Medicare:
1. If you’re already receiving Social Security benefits, you’re usually enrolled automatically in Parts A and B when you turn 65.
2. If not, apply during your Initial Enrollment Period — the 7-month window starting 3 months before your 65th birthday month.
3. Apply online at SSA.gov, by phone, or at a local Social Security office.
4. Missing your window can trigger a late-enrollment penalty added to your Part B premium for as long as you have Medicare, so mark the calendar.
For Medicaid:
1. Apply anytime — there’s no enrollment period, since Medicaid eligibility is need-based and ongoing.
2. Apply through your state Medicaid agency’s website, by phone, or through Healthcare.gov, which will route you to Medicaid if your income qualifies.
3. You’ll need proof of income, residency, and household size. Some states also check assets, especially for long-term care Medicaid.
4. If you’re applying for nursing home Medicaid specifically, ask your state agency about “look-back” rules on asset transfers — these vary and can affect eligibility timing.
FAQ
Does Medicare cover nursing home care?
Only short-term skilled nursing care after a qualifying hospital stay, and only up to 100 days per benefit period, with coinsurance kicking in after day 20. Medicare does not pay for long-term custodial care in a nursing home. That’s typically covered by Medicaid once someone meets the state’s income and asset limits.
If I have Medicare, can I still get Medicaid?
Yes, if your income and assets fall under your state’s Medicaid limits. Many retirees living mainly on Social Security qualify for both. Contact your state Medicaid office to check your state’s specific thresholds, since they vary and are updated annually.
Do I have to pay a premium for Medicaid like I do for Medicare?
Generally no. Most Medicaid enrollees pay little to nothing in premiums, and copays, if any, are small. Medicare, by contrast, always involves some cost-sharing — Part B premiums, deductibles, and 20% coinsurance — unless Medicaid or a supplemental plan is covering those costs for you.
Sources
- Medicare.gov — https://www.medicare.gov
- Medicaid.gov — https://www.medicaid.gov
- Social Security Administration — https://www.ssa.gov
- CMS.gov (Centers for Medicare & Medicaid Services) — https://www.cms.gov
- HHS Poverty Guidelines — https://aspe.hhs.gov/poverty-guidelines
- Healthcare.gov — https://www.healthcare.gov
Related reading
- Social Security COLA for 2026: How Much Bigger Will Your Check Be?
- Medicare Open Enrollment: Dates, What You Can Change, and Costly Mistakes
- Medicare Advantage vs Original Medicare: A Plain-English Comparison