What is the difference between Medicare and Medicaid?
Two different programs with names that sound alike. One is based on age, the other on income, and in Texas the Medicaid rules are stricter than most people expect.
The names are close enough that people use them interchangeably, and then get a surprise at a doctor's office. They are separate programs with separate rules and separate places to apply.
The short version
- Medicare is federal and is based mainly on age. You qualify at 65 regardless of income, or earlier through certain disabilities.
- Medicaid is a joint federal and state program based on income and assets. In Texas it is run by Texas Health and Human Services.
One asks how old you are. The other asks what you earn and own.
What each one covers
Medicare covers hospital care, doctor visits and prescriptions, with premiums, deductibles and coinsurance you pay yourself.
Texas Medicaid covers a similar range plus things Medicare generally does not, most notably long term custodial care in a nursing facility. Costs to the member are very low or nothing at all.
Long term care is the biggest practical difference. Medicare pays for skilled nursing for a limited stretch after a qualifying hospital stay. It does not pay for someone to help with daily living indefinitely. Medicaid does.
Who qualifies for Medicaid in Texas
Texas has not expanded Medicaid, so eligibility is narrower here than in many states. The main groups are children, pregnant women, some parents with very low incomes, people with disabilities, and seniors who meet income and asset limits.
An adult under 65 without children and without a disability generally does not qualify in Texas, no matter how low the income. That gap is real and it catches a lot of people. If that is you, look at the ACA Marketplace instead, where a low income usually means a large subsidy.
Having both at once
You can qualify for both, and around here plenty of people do. That is called being dual eligible. Medicare pays first, Medicaid picks up costs behind it, and together they leave very little for you to pay.
Dual eligibles also get access to a specific kind of Medicare Advantage plan built for that situation, with benefits coordinated across both programs. They tend to be strong plans and they are widely available in Hidalgo County.
The in between programs most people miss
You do not have to qualify for full Medicaid to get help with Medicare costs. Medicare Savings Programs sit in the middle, with higher income limits than full Medicaid.
- QMB pays your Part B premium plus deductibles and coinsurance.
- SLMB and QI pay your Part B premium.
- Qualifying for any of them also opens the door to Extra Help on your prescription costs.
Getting your Part B premium paid means that money goes back into your Social Security check every month. It is worth ten minutes to find out.
Where to apply
- Medicare: Social Security, at ssa.gov or your local office.
- Texas Medicaid and Medicare Savings Programs: Texas Health and Human Services, at yourtexasbenefits.com.
Two different agencies. Applying to one does not start the other.
Common follow-up questions
Can I have Medicare and Medicaid at the same time?
Yes. It is called being dual eligible, and it is common in Hidalgo County. The two programs coordinate, and there are Medicare plans designed specifically for it.
Does Medicaid cover nursing home care in Texas?
Yes, for those who meet the income and asset limits and the level of care requirement. This is the main reason families end up applying.
I am 62, low income, and have no children. Do I qualify for Medicaid in Texas?
Almost certainly not, because Texas did not expand Medicaid. The Marketplace is usually the answer until you turn 65.
Want this looked at properly?
We are an independent agency in McAllen serving Hidalgo, Cameron and Starr counties. No cost to talk it through.
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