Healthcare coverage isn’t one-size-fits-all. Some programs are designed for older adults, while others focus on those with limited income or specific medical needs. Medicare, Medicaid, and MassHealth each have different eligibility rules and benefits, which can make it difficult to determine where you fit in. For Massachusetts residents, MassHealth provides additional coverage that goes beyond standard Medicaid. Whether you’re planning for future medical care or looking for assistance with current expenses, understanding how these programs work can help you get the support you need. Here, we’ll take a closer look at what each program offers and who qualifies.
What Is Medicare?
Medicare is a federal health insurance program primarily for individuals 65 and older. However, it also covers certain younger people with disabilities or specific medical conditions. Unlike Medicaid, Medicare eligibility is not based on income. Instead, it depends on age or disability status.
Who Qualifies for Medicare?
You may be eligible if you:
- Are 65 or older and have worked (or your spouse has worked) and paid Medicare taxes.
- Have a qualifying disability and have received Social Security Disability Insurance (SSDI) for at least 24 months.
- Have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
What Does Medicare Cover?
Medicare is divided into different parts:
- Part A – Hospital stays, skilled nursing facility care, hospice, and some home health care.
- Part B – Doctor visits, outpatient care, medical supplies, and preventive services.
- Part C (Medicare Advantage) – Private insurance alternative combining Parts A and B, often with extra benefits.
- Part D – Prescription drug coverage.
Costs
- Part A is usually free if you have paid Medicare taxes for at least 10 years.
- Parts B, C, and D require premiums, deductibles, and copayments, depending on the plan.
What Is Medicaid?
Medicaid is a joint federal and state program that provides healthcare coverage for individuals and families with limited income. Unlike Medicare, which is primarily based on age, Medicaid eligibility depends on financial need. Each state administers its own Medicaid program within federal guidelines, so coverage and requirements vary.
Who Qualifies for Medicaid?
Eligibility is based on income, household size, and specific circumstances. Medicaid typically covers:
- Low-income adults, including those who are pregnant or disabled.
- Children and families who meet income requirements.
- Seniors who need long-term care but lack the resources to pay for it.
What Does Medicaid Cover?
Medicaid offers broad healthcare coverage, including:
- Doctor visits and hospital stays.
- Prescription drugs.
- Nursing home care and home health services.
- Preventive care, mental health treatment, and emergency services.
Costs
Most Medicaid recipients pay little to nothing for services, though some states require small copayments for certain treatments.
What Is MassHealth?
MassHealth is Massachusetts’ version of Medicaid, providing healthcare coverage for low- to moderate-income individuals and families. It includes both Medicaid and the Children’s Health Insurance Program (CHIP), offering a broader range of benefits than standard Medicaid in other states. Some people qualify for MassHealth alone, while others use it alongside Medicare to reduce out-of-pocket costs.
Who Qualifies for MassHealth?
Eligibility is based on income, household size, and medical needs. MassHealth covers:
- Low-income individuals, families, and children.
- Pregnant women and people with disabilities.
- Seniors who qualify for both Medicare and Medicaid (dual-eligible).
What Does MassHealth Cover?
MassHealth includes:
- Doctor visits, hospital care, and prescription drugs.
- Long-term care, including nursing homes and in-home services.
- Additional benefits, such as dental coverage and personal care assistance.
Costs
Many MassHealth recipients pay little to nothing, though some may have small monthly premiums or copayments based on income.
Key Differences and When Each Program Applies
Medicare, Medicaid, and MassHealth serve different purposes, and some individuals may qualify for more than one. Understanding their differences can help you determine which program best suits your needs.
Key Differences
- Medicare is a federal program based on age or disability, not income. It primarily covers hospital stays, medical visits, and prescription drugs but does not fully cover long-term care.
- Medicaid is a state and federal program that provides healthcare for low-income individuals, including nursing home care.
- MassHealth follows Medicaid rules but offers expanded benefits for Massachusetts residents, including coverage for some individuals with higher incomes.
When Does Each Apply?
The right program depends on your age, income, and healthcare needs. Here are some typical situations and how each program may apply:
- If you are 65 or older and need regular medical care, Medicare will usually be your primary coverage.
- If you have a low income and don’t have health insurance through work, MassHealth may provide full coverage.
- If you are a senior who needs long-term care and has limited assets, you may qualify for Medicaid/MassHealth to help with those costs.
- If you are enrolled in Medicare but have trouble affording premiums or copays, MassHealth may offer additional support to reduce out-of-pocket expenses.
Get the Coverage You Need with the Right Plan
Choosing between Medicare, Medicaid, and MassHealth depends on your age, income, and healthcare needs. While Medicare covers older adults and certain disabilities, Medicaid and MassHealth provide broader support for those with limited income, including long-term care.
If you’re unsure which program applies to you or how to plan for future healthcare costs, we can help. At Surprenant & Beneski, P.C., we assist individuals and families with estate and long-term care planning to ensure financial security. Contact us today to schedule a consultation and explore your options for protecting your health and assets.