What is the difference between medicare and health insurance

Table of Contents Show

The difference between Medicaid and Medicare.
What is Medicaid?
What is Medicare?
The 4 parts of Medicare.
How can you get both Medicaid and Medicare?
What are dual health plans?
What are dual special needs plans?
Is Medicare the same as health insurance?
What is the difference between Medicare and private insurance?
What are the 4 types of Medicare?
What is the main difference between Medicare and Medicaid?

Key differences between Original Medicare and Medicare Advantage

	Original Medicare (Part A and B)	Medicare Advantage Plans (Part C)
Main difference	Medicare pays providers the Medicare-approved rates for covered services per Medicare rules and regulations. Your providers bill Medicare.	Medicare pays private health plans that have contracts with Medicare to provide all medically-necessary health care that Original Medicare (Parts A and B) cover. Your providers bill your Medicare Advantage plan.
Costs	You pay Medicare Parts A and B premiums, deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $148.50 in 2021.	You pay Medicare Parts A and B premiums, and your Medicare Advantage Plans premium, if it charges one, and possible deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $148.50 in 2021.
Supplemental insurance	You may be able to buy a Medigap policy. Other insurance, such as retiree, employer or union plans may supplement Medicare.	You can't buy a Medigap policy to help pay your out-of-pocket costs in a Medicare Advantage plan.
Covers extra services like vision and dental?	No. Covers medically-necessary inpatient and outpatient health care. Doesn't cover certain services such as routine vision, hearing or dental care.	Maybe. May cover some services Original Medicare doesn't cover such as routine vision, hearing and dental care. All plans must cover the same inpatient and outpatient services Original Medicare covers.
Allows me to see providers nationwide?	Yes. You can go to any doctor or hospital in the U.S. that accepts Medicare.	Usually not. Most people have HMOs, which typically have local networks of providers you must use for the plan to cover your care. PPOs plans should cover care you get outside the network, but you will pay more.
Need referrals to see specialist?	No. You don't need a referral.	Maybe. You may need to get a referral from your primary care doctor if you want to see a specialist.
Covers drugs?	No, but if you want Medicare prescription drug coverage, you can buy a separate Part D plan.	Usually. Most plans include Part D drug coverage. In Washington state, if you are enrolled in a Medicare Advantage plan, you cannot buy a standalone Part D plan. If you do, you'll automatically get disenrolled from your Medicare Advantage plan and enrolled in Original Medicare.
Out-of-pocket limits?	No. There's no cap on what you spend on health care.	Yes. Plans must have an annual out-of-pocket limit, which can be high, but protect you if you need expensive care. The plan pays the full cost of your care after you reach the limit.

Definitions:

Premium: The monthly fee you pay to have Medicare or your health plan.
Deductible: What you must pay before Medicare or your health plan starts paying for your care.
Copayment/coinsurance: Your share of the cost you pay for each service.
Part A: Medicare hospital insurance for inpatient care.
Part B: Medicare medical insurance for outpatient care.
Part D: Medicare drug coverage.
Medigap: Supplemental insurance that helps pay your out-of-pocket cost in Original Medicare.

Posted: January 17, 2020

Last updated date: April 02, 2021

Medicaid and Medicare. It’s hard to think of two words that cause as much confusion.

What’s the difference between these two government health insurance programs?
What exactly are Medicaid and Medicare?
Who’s eligible to get Medicaid or to get Medicare?
And how can some people get both?

Read on to find out the answers to these questions and more.

Everything you need to know about Dual Special Needs Plans in one, convenient guide.

The difference between Medicaid and Medicare.

The difference between Medicaid and Medicare is that Medicaid is managed by states and is based on income. Medicare is managed by the federal government and is mainly based on age. But there are special circumstances, like certain disabilities, that may allow younger people to get Medicare.

What is Medicaid?

Medicaid is a way to get health care at a lower cost or sometimes at no cost to you. Medicaid is managed by each state, so the eligibility requirements can change from state to state. Your state may even have its own name for its Medicaid program. It’s important to remember that you have to recertify for Medicaid each year.

Medicaid typically covers:

Children
Pregnant women
Elderly adults and people with disabilities
Eligible low-income adults

What is Medicare?

Medicare is a national health insurance program run by the federal government. Medicare covers:

People age 65 and older.
Some people under age 65 who may qualify due to a disability or another special situation.

Medicare helps millions of American seniors and disabled individuals cover some of their health care costs. There are 4 different parts to Medicare. This helps give people more health care choices, so they can pick the health care plan that best meets their needs.

The 4 parts of Medicare.

FYI: Parts A and B are also known as “Original Medicare.”

Part A

Helps pay for hospital stays and inpatient care.

Part B

Helps pay for doctor visits and outpatient care.

Private insurance companies offer other types of Medicare plans with extra benefits that go beyond Original Medicare:

Part C

Combines Part A (hospital insurance) and Part B (medical insurance) in one plan that often includes prescription drug coverage too.

Part D

Prescription drug coverage.

How can you get both Medicaid and Medicare?

Some people qualify for Medicare because of age (they’re age 65 or older) or due to having a disability. They’re also eligible for Medicaid because they meet the requirements to qualify for Medicaid in their state. These people are “dual eligible” because they’re eligible for both Medicaid and Medicare.

What are dual health plans?

Dual health plans are designed just for people who have both Medicaid and Medicare. They’re a special type of Medicare Part C (Medicare Advantage) plan. Dual health plans combine hospital, medical and prescription drug coverage. You’ll keep all your Medicaid benefits. Plus, you could get more benefits than with Original Medicare. And you could get it all with as low as a $0 plan premium.

View the "Do I Lose My Medicaid Benefits?" article.

What are dual special needs plans?

Dual health plans are also known as dual special needs plans. They’re offered by private insurance companies, so you can find a dual health plan that best meets your health insurance needs. Being on a dual health plan does not change your Medicaid eligibility or benefits.

Dual-eligible or Medicaid plan benefits can change depending on where you live. Search using your ZIP code to find the best plan to meet your health care needs.

Is Medicare the same as health insurance?

Medicare is the federal health insurance program for: People who are 65 or older. Certain younger people with disabilities.

What is the difference between Medicare and private insurance?

The difference between private health insurance and Medicare is that Medicare is mostly for individual Americans 65 and older and surpasses private health insurance in the number of coverage choices, while private health insurance allows coverage for dependents.

What are the 4 types of Medicare?

There are four parts of Medicare: Part A, Part B, Part C, and Part D..

Part A provides inpatient/hospital coverage..

Part B provides outpatient/medical coverage..

Part C offers an alternate way to receive your Medicare benefits (see below for more information)..

Part D provides prescription drug coverage..

What is the main difference between Medicare and Medicaid?

Medicare is a medical insurance program for people over 65 and younger disabled people and dialysis patients. Medicaid is an assistance program for low-income patients' medical expenses.