What is the difference between Medicare and Medicaid?
Medicare is based on age and starts at 65. Medicaid is based on income and what you own, and in Texas the rules are stricter than most people expect.
- Medicare is based on age and starts at 65 no matter what you earn, while Medicaid is based on income and what you own.
- Texas did not expand Medicaid. An adult under 65 with no children and no disability usually does not qualify, no matter how low the income.
- You can have both, and Medicare Savings Programs can pay your Part B premium even if you do not qualify for full Medicaid.
Medicare is federal health insurance based mainly on age. You qualify at 65 no matter what you earn, or earlier through certain disabilities. Medicaid is based on income and assets, meaning what you earn and what you own. It is run jointly by the federal government and the state.
They are separate programs with separate rules and separate places to apply. In Texas, Medicaid is run by Texas Health and Human Services, which publishes the current rules at hhs.texas.gov.
Medicare is based on age, Medicaid on income
- Medicare is federal and is based mainly on age.
- Medicaid is a joint federal and state program based on income and assets.
To keep them straight, remember that Medicare looks at your age. Medicaid looks at what you earn and own. See how Medicare works.
What each one covers
Medicare covers hospital care, doctor visits and prescriptions. You pay part of the cost yourself. That comes as premiums (the monthly bill), deductibles (the amount you pay before coverage starts paying) and coinsurance (your percentage share of each bill).
Texas Medicaid covers a similar range, plus things Medicare generally does not. The biggest one is long term custodial care in a nursing facility, which means day to day help with things like bathing, dressing and eating. You pay very little or nothing.
Long term care is the biggest practical difference. Medicare pays for skilled nursing, which is care from nurses and therapists, for a limited stretch after a qualifying hospital stay. It does not pay for someone to help with daily living for as long as you need it. Medicaid does.
Who qualifies for Medicaid in Texas
Texas has not expanded Medicaid, so fewer people qualify here than in many states. The main groups are children, pregnant women, and some parents with very low incomes. People with disabilities and seniors who meet the income and asset limits also qualify.
An adult under 65 with no children and no disability usually does not qualify in Texas, no matter how low the income. If that is you, look at the ACA Marketplace instead. There, a low income usually means a large subsidy, which is money the government pays toward your premium.
Having both: dual eligibility
You can qualify for both programs, and many people in South Texas do. That is called being dual eligible. Medicare pays first, and Medicaid picks up costs behind it. Together they leave very little for you to pay.
People who are dual eligible can also join a special kind of Medicare Advantage plan built for them. Medicare Advantage is a private plan that delivers your Medicare coverage. These plans combine benefits from both programs, and they are widely available in Hidalgo County.
The in between programs for people who do not qualify for full Medicaid
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.
- The Qualified Medicare Beneficiary program (QMB) pays your Part B premium, the monthly bill for the part of Medicare that covers doctor visits. It also pays your deductibles and coinsurance.
- The Specified Low Income Medicare Beneficiary program (SLMB) and the Qualifying Individual program (QI) pay your Part B premium.
- Qualifying for any of them also opens the door to Extra Help, a federal program that lowers what you pay for prescriptions.
Getting your Part B premium paid means that money goes back into your Social Security check every month. It takes about ten minutes to find out whether you qualify.
Where to apply
- Medicare: Social Security, at ssa.gov or your local Social Security office.
- Texas Medicaid and Medicare Savings Programs: Texas Health and Human Services, at yourtexasbenefits.com.
These are two different agencies. Applying to one does not start the other.
If you are near 65, apply for Medicare through Social Security first. Then check whether your income fits a Medicare Savings Program through Texas Health and Human Services. If you are not sure where you stand, call our office in McAllen and we will help you sort it out.
Common follow-up questions
Can I have Medicare and Medicaid at the same time?
Yes. That is called being dual eligible, and it is common in Hidalgo County. The two programs work together, and there are Medicare plans designed for exactly that situation.
Does Medicaid cover nursing home care in Texas?
Yes, for people who meet the income and asset limits and need that level of care. This is the main reason families end up applying for Medicaid.
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. There is no obligation to talk it through.
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Gerino Alejos
Licensed insurance agent · License 3128710 · NPN 18243381
Owner of McAllen Insurance Group, an independent agency on North 10th Street in McAllen. Works with clients across Hidalgo, Cameron and Starr counties on Medicare, Marketplace health, life and auto coverage. Se habla español.