Difference Between Medicare and Medicaid (2025 Edition) – A Clear, Side-by-Side Guide

In a hurry? Skip to Section 2 for the comparison table or Section 8 for the provider-enrollment checklist.

Key Summary (30-Second Read)

• Medicare is a federal health-insurance program for most people age 65+ and younger adults with certain disabilities or end-stage renal disease (ESRD).
• Medicaid is a joint federal–state program that offers free or very low-cost coverage to people of any age whose income and assets meet state rules; benefits vary by state.
• Almost 12 million Americans are “dual eligible,” receiving both programs and paying little—or nothing—out of pocket.
• Medicare is divided into Parts A, B, C and D; Medicaid has no parts, but each state controls income limits, asset tests and optional benefits.
• Providers—hospitals, physicians, home-health agencies, pharmacies—need separate approvals to bill Medicare and their state’s Medicaid program.

Table of Contents

1. Medicare Basics: Parts A, B, C & D
2. Medicare vs. Medicaid: Quick-Look Comparison
3. Medicaid 101: Eligibility & Mandatory Benefits
4. Dual Eligibility: How the Two Programs Work Together
5. Cost Breakdown: Premiums, Deductibles & Copays
6. Enrollment Windows & How to Sign Up
7. Common Myths—Debunked
8. Provider Corner: Becoming an Approved Medicare & Medicaid Biller
9. How CarePolicy.US Can Help (Consumers & Providers)
10. Frequently Asked Questions
11. Bottom Line & Next Steps

1. Medicare Basics

The following table:

Medicare Part	What It Covers	2025 Cost Snapshot*	Key Enrollment Timing
Part A (Hospital)	In-patient hospital stays, skilled-nursing-facility care, hospice, limited home-health	Premium-free for most; inpatient deductible ≈ $1,740 per benefit period	Automatic at 65 if already receiving Social Security
Part B (Medical)	Doctor visits, outpatient care, preventive services, durable medical equipment	Standard premium ≈ $176.20/mo; annual deductible ≈ $250	Initial Enrollment Period (IEP): 7-month window around 65th birthday
Part C (Medicare Advantage)	Private plan that bundles Parts A & B (often Part D) plus extra benefits like dental/vision	Many $0-premium plans; copays vary by plan	Annual Election Period (AEP): Oct 15 – Dec 7
Part D (Prescription Drugs)	Outpatient prescription medications	Average basic premium ≈ $36/mo; deductible capped at ≈ $545	Same election windows as Part C

*Figures are CMS estimates for plan year 2025; final numbers post each October.

2. Medicare vs. Medicaid: Quick-Look Comparison

The following table:

Feature	Medicare	Medicaid
Who administers it?	Federal CMS	State Medicaid agency with CMS oversight
Who qualifies?	Age 65+ or <65 with disability/ESRD/ALS	Income & asset limits plus categorical rules (kids, pregnant, aged, disabled)
Premiums?	Yes — Parts B, C, D	Usually $0; some states charge small premiums
Deductibles & copays?	Yes — vary by Part; Medigap or Advantage can offset	Minimal or none; states may charge nominal cost-sharing
Benefit uniformity	Same nationwide	Core benefits required; many options differ by state
Long-term custodial care	Not covered (only short-term skilled)	Covered once financial and level-of-care tests met
Funding source	Payroll taxes, enrollee premiums, general revenue	Joint funding: state budgets + open-ended federal match
Enrollment periods	Strict windows (IEP, GEP, AEP)	Year-round; must re-verify eligibility

3. Medicaid 101: Eligibility & Mandatory Benefits

Federal “Floor” Benefits (all states must cover)

• In-patient and outpatient hospital services
• Physician, laboratory and X-ray services
• Nursing-facility care and home-health services
• Family-planning services and supplies
• Early & Periodic Screening, Diagnostic and Treatment (EPSDT) for children

Common Optional Benefits States Add

• Prescription drugs
• Dental, vision, hearing
• Personal-care aides and Home- & Community-Based Services (HCBS) waivers
• Non-emergency medical transportation

Eligibility Rules

• MAGI pathway: children and expansion adults ≤ 138% FPL (optional in 10 non-expansion states).
• Aged, blind, disabled: income limits closer to SSI plus an asset cap (commonly $2,000 single / $3,000 couple).
• Most states allow spend-down or “medically needy” routes; some use Miller (QIT) trusts.

4. Dual Eligibility – Using Both Programs Together

If you have Medicare and meet your state’s Medicaid limits, Medicaid becomes payer of last resort:

• Pays Medicare Part B (and sometimes Part A) premiums.
• Covers Medicare deductibles and coinsurance.
• Funds long-term custodial care or extra home-care hours Medicare does not provide.
• Explore Medicare Savings Programs (QMB, SLMB, QI, QDWI) and Part D Extra Help for automatic premium and copay relief.

5. Cost Breakdown (2025 Estimates)

The following table:

Cost Layer	Medicare-Only	Medicaid-Only	Dual Eligible
Monthly Premium	Part B ≈ $176.20	Usually $0	$0 (Medicaid pays)
Annual Deductible	Part A ≈ $1,740 ; Part B ≈ $250	Often $0	Medicaid covers Medicare deductibles
Drug Copay	Tiered up to 25% (Part D)	Nominal ≤ $4.50 generic	Extra Help: $0–$4.50
Long-Term Care	Private pay after 100 Medicare days	Covered if financially and clinically eligible	Covered by Medicaid

6. Enrollment Windows & How to Sign Up

Medicare

• Initial Enrollment Period (IEP) – 3 months before → 3 months after 65th birthday.
• General Enrollment Period (GEP) – Jan 1 – Mar 31 if you missed IEP (penalties may apply).
• Annual Election Period (AEP) – Oct 15 – Dec 7 to switch Part C or Part D plans.
• Apply at SSA.gov or call Social Security (800-772-1213).

Medicaid

• Apply any time via your state Medicaid website or HealthCare.gov (expansion states).
• Re-verify income/assets at least every 12 months; some groups (kids, pregnancy) may have continuous eligibility.

7. Common Myths—Debunked

The following table:

Myth	Reality
“Medicare covers forever in a nursing home.”	Only up to 100 days per benefit period and only for skilled services.
“Medicaid is only for people on welfare.”	Over half of enrollees are children or working adults; many seniors rely on Medicaid for long-term care.
“Medicare Advantage is Medicaid.”	Medicare Advantage = private Medicare plan; Medicaid managed care is separate.
“I’m over Medicaid income limit—no help for me.”	Medicare Savings Programs use higher income limits; states may offer spend-down or Miller trust options.

8. Provider Corner: Becoming an Approved Medicare & Medicaid Biller

The following table:

Phase	Medicare Tasks	Medicaid Tasks	Typical Timeline
Prereqs	Obtain Type 2 NPI, set up PECOS account.	Register in state Medicaid portal.	1 – 2 weeks
Application	Submit CMS-855 form (I/A/B depending on provider type) with license, ownership & banking docs.	File state Medicaid enrollment with W-9, insurance, license.	2 – 4 weeks
Screening & Site Visit	Background checks; possible fingerprinting or site visit.	Many states echo Medicare site visit; managed-care plans add credentialing reviews.	4 – 12 weeks
Approval	MAC issues PTAN and effective billing date.	State grants Medicaid Provider ID; contract with managed-care organizations.	2 – 6 weeks
First Claims & Compliance	EDI setup, OASIS or cost-report data, revalidation every 5 years (2 years for DME).	State encounter-data rules; revalidate every 3 – 5 years.	Ongoing

Accreditation (ACHC, CHAP, Joint Commission) can speed Medicare approval for agencies but adds cost (≈ $12k – $18k over 3 years).

9. How CarePolicy.US Can Help (Consumers & Providers)

The following table:

Need	CarePolicy.US Solution	Best For
Am I eligible?	Free Medicare-vs-Medicaid “fit check” quiz and live counselor call.	Individuals & caregivers
Dual-eligibility paperwork	Step-by-step kits for Medicare Savings Programs, Extra Help, spend-down and Miller trust strategies.	Seniors & disabled adults
Provider licensing & policies	Turn-key state-license road maps, policy manuals, mock surveys synced with CMS rules.	Home-health agencies, hospices, clinics
Medicare/Medicaid enrollment	End-to-end NPI, PECOS 855, Medicaid portal filings, managed-care contracting, PTAN tracking.	Physicians, agencies, therapy groups
Ongoing compliance	Quarterly policy updates, revalidation alerts, audit-response coaching, HIPAA/security tool kits.	All enrolled providers
CEU & staff training	Web-based courses on Medicare billing, Medicaid documentation, fraud-waste-abuse prevention.	Administrators & clinical staff

Fast-Track Bundles

• Essentials – DIY templates + phone support
• Premium – Full provider-enrollment service (state + CMS + Medicaid)
• Turn-Key – Concept-to-claim project management, including staff onboarding

Clients cut average time-to-first Medicare claim by 35% and achieve a 98% first-pass approval rate on state-license submissions (2024 audit).

Book a complimentary 30-minute strategy call at CarePolicy.US to move from confusion to confident coverage—or compliant billing—fast.

10. Frequently Asked Questions

Q1. Can I keep employer insurance and delay Medicare?
Yes. If your employer plan is creditable, you can delay Part B; sign up within 8 months of losing that coverage to avoid penalties.

Q2. Does Medicaid always cover dental and vision?
No. These benefits are optional; coverage for adults varies widely by state.

Q3. Can higher-income seniors get help with Medicare costs?
Possibly. Medicare Savings Programs and Extra Help have higher income ceilings than full Medicaid.

Q4. Will my spouse’s assets disqualify me from Medicaid?
“Spousal-impoverishment” rules protect a minimum resource allowance for the community spouse.

Q5. How does the Inflation Reduction Act affect drug spending?
In 2025, Part D out-of-pocket costs cap at $2,000 and insulin remains capped at $35/month.

11. Bottom Line & Next Steps

• Medicare = age/disability-based federal insurance.
• Medicaid = income-based state safety net.

When you qualify for both, you eliminate nearly all out-of-pocket costs.

Providers must secure separate approvals before billing each program.

Need a co-pilot? CarePolicy.US offers one-on-one eligibility counseling for consumers and full-service enrollment/credentialing for providers—so you focus on health, not paperwork.