Medicare is federal health insurance mainly for people age 65 and older, plus some younger people with qualifying disabilities or conditions. Medicaid is a joint federal–state program for people who meet their state’s eligibility rules, which can include income, resources, residency and other factors. They are separate programs, but some people qualify for both. When that happens, Medicare generally pays first for Medicare-covered care and Medicaid pays after Medicare and other insurance.
The practical difference is that Medicare eligibility is based chiefly on age or specified medical status, while Medicaid eligibility and benefits depend on the state and eligibility category. Medicare’s benefits are organized into Parts A, B, C and D; Medicaid can add services Medicare does not normally cover, including some long-term-care and personal-care services.
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Medicare and Medicaid at a glance
| Question | Medicare | Medicaid |
|---|---|---|
| Who runs it? | Federal government program administered by the Centers for Medicare & Medicaid Services (CMS). | Joint federal–state program. Each state administers its program within federal requirements. |
| Main eligibility basis | Usually age 65 or older; also available to some younger people with qualifying disabilities or conditions. | State rules that may consider income, resources, residency, household circumstances, age, disability, pregnancy or other categories. |
| Where benefits come from | Original Medicare (Parts A and B), a Medicare Advantage plan (Part C), and prescription-drug coverage (Part D). | A state Medicaid program; covered services and financial rules vary by state and eligibility group. |
| Typical role | Medical and hospital insurance for older adults and certain disabled people. | Health coverage and financial protection for eligible low-income people and other specified groups; can cover services Medicare excludes or only partly covers. |
| Can someone have both? | Yes. A person enrolled in both is often called “dual eligible.” Medicare generally pays first for Medicare-covered services; Medicaid pays last. | |
CMS explains the programs and dual-eligibility rules on its Medicaid information page and its page explaining the Parts of Medicare.
Who qualifies for Medicare?
Age-based eligibility
Most people first qualify for Medicare at age 65. Eligibility is separate from financial need: a person can qualify regardless of income or assets. Premium-free Part A is usually available when the person or a spouse has enough Medicare-covered work history, but people without sufficient work history may have to buy Part A.
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Eligibility before age 65
Some people younger than 65 can receive Medicare after qualifying for Social Security disability benefits or because they have certain conditions. The exact waiting periods and condition-specific rules are administered through the federal Medicare and disability systems. A disability-related Medicare entitlement does not, by itself, establish Medicaid eligibility.
Enrollment timing matters
People approaching 65 generally have an initial enrollment period around their 65th birthday. Someone who continues working and has employer coverage may have different enrollment choices, while delaying Part B without qualifying coverage can create later enrollment penalties. Check the person’s own Social Security and Medicare notices for the applicable dates rather than assuming every employment situation is identical.
Who qualifies for Medicaid?
State-specific financial and personal rules
There is no single nationwide Medicaid income limit that applies to every applicant. States set rules within federal guidelines, and the threshold can differ by eligibility group. States may evaluate income, countable resources, residency, household composition, age, disability, pregnancy, children in the household and other factors. Some categories use different financial tests or do not use an asset test in the same way.
Because the rules are state-specific, an online rule of thumb cannot determine eligibility for a particular person. Apply through the state Medicaid or Medical Assistance agency, and ask which eligibility category is being evaluated. Some states use names such as Medical Assistance or Medi-Cal.
Residency and documentation
Applicants generally must live in the state where they apply and provide information needed to verify identity, residency, income and other eligibility factors. The agency—not a general Medicare comparison chart—makes the individual determination. Report changes such as moving, changes in income, household size or disability status because they can affect eligibility and renewal.
Future policy changes need a date and scope
Medicare.gov identifies a work or approved-activity requirement beginning in 2027 for certain adults in some circumstances. That information does not create a work requirement for every Medicaid beneficiary and does not apply to Medicare enrollment generally. Ask the state agency how any future rule affects the specific eligibility group.
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What Medicare covers
Part A: hospital insurance
Part A covers eligible inpatient hospital care and certain related services, such as skilled nursing facility care under Medicare’s conditions, hospice and limited home health services. It is not a blanket payment for every nursing-home stay or every long-term-care need. Most beneficiaries pay no monthly Part A premium because of work history; others can buy Part A.
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Part B covers medically necessary doctor services, outpatient care, preventive services and covered medical supplies. It normally requires a monthly premium and an annual deductible, followed by cost sharing for covered services. Part B does not automatically pay for every dental, vision, hearing, custodial-care or long-term-care service.
Part C: Medicare Advantage
Medicare Advantage is a private-plan alternative for receiving Medicare benefits. Plans must cover services that Original Medicare covers, and many offer additional benefits. Each plan sets its own premiums, cost-sharing rules, provider network and prior-authorization requirements. Availability and details depend on the county and plan.
Part D: prescription drugs
Part D provides outpatient prescription-drug coverage through private plans. Formularies, pharmacy networks, premiums and cost sharing differ by plan. A person choosing Original Medicare generally adds a stand-alone Part D plan; many Medicare Advantage plans include drug coverage.
What Medicaid can cover that Medicare may not
Medicaid benefits are not identical across states, so the following are examples rather than a guaranteed package. The Medicare & You 2026 handbook lists services that full Medicaid may cover when Medicare does not or covers only partly:
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- Long-term care in a nursing home.
- Personal-care services.
- Transportation to medical appointments.
- Home- and community-based services.
- Home-delivered meals.
- Some dental, vision and hearing services.
Whether a service is available, how much a person must pay, and whether prior authorization is required depend on the state program and the person’s Medicaid category. Medicaid may also cover Medicare premiums or cost sharing for eligible beneficiaries through Medicare Savings Programs.
How much does Medicare cost in 2026?
The figures below are Medicare amounts for 2026. They can change in later years, and an individual’s total depends on coverage choice, income, health-care use and plan terms.
| 2026 item | Amount or rule | Qualification |
|---|---|---|
| Standard Part B premium | $202.90 per month | Centers for Medicare & Medicaid Services standard premium for 2026; higher-income beneficiaries may pay more. |
| Part B deductible | $283 | Annual deductible for 2026 before Part B cost sharing applies. |
| Part A deductible | $1,736 per benefit period | 2026 inpatient hospital deductible; it is per benefit period, not a single once-per-year deductible. |
| Premium-free Part A | $0 monthly for most people | Usually based on sufficient Medicare-covered work history. |
| Buy-in Part A premium | $311 or $565 per month | 2026 amounts depend on the person’s work history. |
| Medicare Advantage premium and cost sharing | Varies by plan | Compare the specific plan’s premium, network, deductibles, copayments, coinsurance and annual out-of-pocket limit. |
| Part D premium and cost sharing | Varies by plan | Formulary, pharmacy network, income-related charges and plan design affect the total. |
CMS publishes the annual figures on What does Medicare cost? and explains broader cost rules on its Medicare costs page.
Original Medicare has no general yearly out-of-pocket cap
Original Medicare generally lets a beneficiary use any doctor or hospital that accepts Medicare, but it does not have a yearly out-of-pocket maximum for Part A and Part B by itself. A Medigap policy, employer coverage or Medicaid can change the amount the beneficiary personally pays. Prescription-drug costs are handled separately through Part D.
Medicare Advantage has a plan-specific annual limit
Medicare Advantage plans must include an annual out-of-pocket limit for covered Part A and Part B services. The limit and the costs that count toward it are plan-specific. A lower premium does not necessarily mean lower total spending if the person uses many services or faces network and authorization restrictions.
Can I have both Medicare and Medicaid?
Yes. A person who meets Medicare rules and a state’s Medicaid rules can be enrolled in both. The level of Medicaid assistance varies: some people receive full Medicaid benefits, while others qualify for a Medicare Savings Program that helps with premiums and/or cost sharing but does not provide the full Medicaid benefit package.
Which program pays first?
For a Medicare-covered service, Medicare pays first. Medicaid pays last, after Medicare and any other health insurance. This coordination rule is stated on CMS’s Medicaid page. Providers must bill the primary coverage before Medicaid can consider the remaining amount.
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What Medicaid may pay for a dual eligible
Depending on the Medicaid category and state, Medicaid may pay the Part B premium, some Medicare deductibles and coinsurance, and possibly a Part A premium. Full-benefit Medicaid recipients automatically receive Extra Help with Medicare prescription-drug costs. Medicaid can also pay for certain drugs or services that Medicare excludes, subject to state rules.
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Medicare Savings Programs are Medicaid-administered programs for eligible Medicare beneficiaries. The state determines eligibility and the precise assistance. Details are outlined on CMS’s Medicare Savings Programs page. Applying is worthwhile even when someone does not qualify for full Medicaid because premium assistance can materially reduce monthly expenses.
Original Medicare or Medicare Advantage?
Choosing how to receive Medicare is a separate decision from applying for Medicaid. Compare the options using the person’s doctors, prescriptions, travel pattern and expected care—not just the advertised premium.
| Factor | Original Medicare | Medicare Advantage |
|---|---|---|
| Provider access | Generally any doctor or hospital that accepts Medicare. | Usually a plan network; out-of-network rules vary by plan type. |
| Prior authorization | Less common, though some services have coverage rules. | Plans may require prior authorization or referrals for specified services. |
| Prescription drugs | Usually add a separate Part D plan. | Many plans include Part D; verify the formulary and pharmacies. |
| Out-of-pocket protection | No general annual Part A and Part B maximum without supplemental coverage. | Annual maximum for covered Part A and Part B services, set by the plan. |
| Extra benefits | Standard Medicare benefits; supplemental coverage may add protection. | Some plans offer extras, but benefits, limits and eligibility vary. |
| Travel and local availability | Broad national provider access where Medicare is accepted. | Service area and network rules can matter, especially outside the plan’s region. |
CMS provides a feature-by-feature comparison in Compare Original Medicare and Medicare Advantage. A plan’s premium should be weighed alongside its deductible, copays, coinsurance, network, referral rules, prior authorization and annual limit.
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Applying for Medicare
- Review the enrollment information sent by Medicare or Social Security before turning 65, or when a disability-related entitlement is approaching.
- Confirm whether Part A is premium-free based on your or your spouse’s work history.
- Decide whether to enroll in Part B when first eligible. If you have employer coverage, verify with the employer whether it qualifies to delay Part B without a penalty.
- Choose between Original Medicare and Medicare Advantage during an applicable enrollment period, then arrange Part D or other supplemental coverage when needed.
Applying for Medicaid
- Contact the state Medicaid, Medical Assistance or similarly named agency where you live.
- Ask which eligibility group applies and what income, resource, residency and household documents are required.
- Submit the application and report requested changes promptly. The state—not Medicare—makes the Medicaid eligibility decision.
- If approved, ask when coverage begins, which services require authorization and whether a managed-care plan selection is required.
Getting unbiased counseling
State Health Insurance Assistance Programs (SHIPs) provide local counseling on Medicare choices and dual-eligibility issues. The 2026 handbook advises people with both programs to consult a local SHIP. Use the state-specific contact information in the official Medicare & You handbook or your state’s agency website.
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You are turning 65 and have limited income
Apply for Medicare on its normal schedule, then apply separately for Medicaid or a Medicare Savings Program. Do not assume Medicare enrollment disqualifies you from Medicaid; the programs use different rules.
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You already receive Medicaid and are approaching 65
Ask the state agency and Social Security how your coverage will coordinate when Medicare starts. Medicaid may continue, change category or help with Medicare premiums and cost sharing, but the result depends on your state and eligibility group.
You need nursing-home or in-home personal care
Medicare may cover limited skilled services under its conditions, but it is not general long-term-care insurance. Ask Medicaid about nursing-facility coverage and home- and community-based services, including financial and functional eligibility requirements.
Your doctor is not in a Medicare Advantage network
Check whether the plan permits out-of-network care, whether a referral or prior authorization is needed, and what the cost would be. If broad provider choice is essential, compare the same doctors under Original Medicare before enrolling.
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Your prescription costs are difficult to afford
Check Part D plan formularies and pharmacies. If you have full Medicaid, Extra Help is automatic; otherwise, ask about eligibility for prescription assistance through Medicare Savings or Extra Help programs.
Errors that can create avoidable costs
- Using a nationwide Medicaid cutoff. A rule quoted for one state or eligibility group may be wrong for another. Get a state determination.
- Assuming Medicare covers custodial long-term care. Medicare coverage is limited and condition-based; ask Medicaid about long-term services.
- Comparing premiums only. Include deductibles, copays, coinsurance, drug costs, networks, authorization rules and annual limits.
- Failing to tell providers about both programs. Give every provider current Medicare and Medicaid information so claims can be coordinated in the right order.
- Missing enrollment periods. Delayed Part B or Part D enrollment can have financial consequences unless qualifying coverage or an exception applies.
- Treating 2026 figures as permanent. Medicare premiums and deductibles are annual amounts; verify the year before making a budget or enrollment decision.
Where to verify your exact benefits
Use Medicare.gov for federal eligibility, enrollment and cost information, and contact your State Medical Assistance or Medicaid office for state-specific eligibility and benefits. The official Medicare & You 2026 handbook describes full Medicaid examples and dual-eligible coordination, while the Parts of Medicare guide explains what each Medicare part does.
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