What Is the Difference Between Medicare and Medicaid?

Why the Confusion Between Medicare and Medicaid?

Medicare and Medicaid were both created in 1965, their names sound almost identical, and they both help people pay for health care. No wonder so many people mix them up. But they work very differently, and understanding those differences can save you real money, stress, and time, especially if you are approaching 65, caring for an aging parent, or managing a disability.

Let's walk through each program in plain language so you know exactly what you are dealing with.

What Is Medicare?

Medicare is a federal health insurance program. It is run by the Centers for Medicare and Medicaid Services (CMS), and the rules are the same no matter which state you live in.

Who Qualifies for Medicare?

• Adults 65 and older who are U.S. citizens or permanent legal residents (and who have lived in the U.S. for at least five continuous years).
• People under 65 with certain disabilities who have received Social Security Disability Insurance (SSDI) for 24 months.
• People of any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant) or ALS (Lou Gehrig's disease).

Eligibility is based on age or medical condition, not income.

The Four Parts of Medicare

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility stays (up to 100 days following a qualifying hospital stay), hospice care, and some home health services. Most people pay no monthly premium for Part A if they or a spouse paid Medicare taxes for at least 10 years.
• Part B (Medical Insurance): Covers doctor visits, outpatient services, preventive screenings, lab work, durable medical equipment, and mental health services. The standard Part B premium in 2025 is $185 per month, though higher earners pay more.
• Part C (Medicare Advantage): An alternative way to receive Part A and Part B benefits through a private insurance plan approved by Medicare. Many Advantage plans bundle prescription drug coverage and extras like dental and vision. In the Oklahoma City metro, several major insurers offer Medicare Advantage plans with varying networks and costs.
• Part D (Prescription Drug Coverage): A separate plan you can add to Original Medicare (Parts A and B) to help cover the cost of prescription medications. Premiums, formularies, and copays vary by plan.

You can also purchase a Medigap (Medicare Supplement) policy from a private insurer to help cover out-of-pocket costs like deductibles and coinsurance under Original Medicare. Medigap and Medicare Advantage cannot be used together.

What Is Medicaid?

Medicaid is a joint federal and state program. The federal government sets minimum standards, but each state runs its own version with its own name, eligibility thresholds, and covered services.

Who Qualifies for Medicaid?

Eligibility is based primarily on income and resources. Covered groups typically include low-income adults, children, pregnant women, elderly adults, and people with disabilities. Each state sets its own income limits.

Medicaid in Oklahoma: SoonerCare

In Oklahoma, Medicaid is called SoonerCare and is administered by the Oklahoma Health Care Authority (OHCA). Oklahoma expanded Medicaid in 2021, which means adults ages 19 to 64 with household incomes at or below 138% of the federal poverty level may now qualify, even without children or a disability.

You can apply for SoonerCare online at mysoonercare.org, by calling 1-800-987-7767, or by visiting a local OHCA or Department of Human Services office.

What Does Medicaid Cover?

Medicaid typically covers a broad range of services, often with little or no cost to the enrollee:

• Doctor and hospital visits
• Prescription drugs
• Lab tests and X-rays
• Home health and personal care services
• Long-term nursing home care (this is a critical distinction, since Medicare does not cover long-term custodial care)
• Transportation to medical appointments (in many states, including Oklahoma)

Medicare vs. Medicaid: A Side-by-Side Comparison

• Who runs it: Medicare is federal. Medicaid is federal and state together.
• Eligibility basis: Medicare is based on age or disability. Medicaid is based on income and resources.
• Premiums: Medicare generally requires monthly premiums (especially Part B and Part D). Medicaid has little to no premiums for most enrollees.
• Long-term care: Medicare covers only short-term skilled nursing stays. Medicaid is the primary payer for long-term nursing home care.
• Prescription drugs: Medicare requires a separate Part D plan or an Advantage plan with drug coverage. Medicaid usually includes prescription drug coverage.

Can You Have Both? Understanding Dual Eligibility

Yes. If you meet Medicare's age or disability requirements and have limited income and resources, you may qualify for both programs at the same time. People in this situation are called dual eligibles.

Being dual eligible can significantly lower your health care costs. Medicaid may pay your Medicare premiums, deductibles, and copays. It may also cover services that Medicare does not, such as long-term care, dental care, and transportation.

Medicare Savings Programs

Even if you do not fully qualify for Medicaid, your state may offer Medicare Savings Programs that help pay some or all of your Medicare costs. In Oklahoma, these programs are administered through the Oklahoma Health Care Authority. Income limits are higher than standard Medicaid, so it is worth checking even if you think your income is too high for Medicaid.

To find out if you qualify, contact Oklahoma SHIP (State Health Insurance Assistance Program) at 1-800-763-2828. SHIP counselors provide free, unbiased help. They do not sell insurance.

How to Get Help Navigating Your Options

Understanding which program (or programs) you qualify for can feel overwhelming, especially during open enrollment periods or after a major life change like retirement, a diagnosis, or the loss of a spouse. Here are reliable places to start:

• Medicare.gov: The official federal site for Medicare information, plan comparisons, and enrollment.
• Oklahoma SHIP: Free Medicare counseling at 1-800-763-2828.
• Oklahoma Health Care Authority (SoonerCare): 1-800-987-7767 or mysoonercare.org for Medicaid questions and applications.
• Eldercare Locator: A national service at 1-800-677-1116 that connects you with local aging resources, including Area Agencies on Aging across Oklahoma.
• Social Security Administration (SSA): Handles initial Medicare enrollment. Visit ssa.gov or call 1-800-772-1213.

Key Takeaways

Medicare and Medicaid are two separate programs with different rules, different funding, and different purposes. Medicare is primarily about age. Medicaid is primarily about income. They can work together if you qualify for both, and several programs exist specifically to help people in that overlap.

The single most important step you can take is to check your eligibility for both programs rather than assuming you only qualify for one. Free help is available, and you do not have to figure it out alone.

If you are ready to talk through your specific situation with someone who knows the landscape, Second Half 365 can connect you with a verified local expert in the Oklahoma City area (or beyond) who specializes in Medicare, Medicaid, and benefits planning. Reach out through our directory to find the right fit for your family.