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state must provide coverage for some individuals who receive federally assisted income maintenance payments and similar groups who do not receive cash payments.

The federal government also consider some other groups to be “categorically needy.” People in these groups must also be eligible for Medicaid.

They include:

Children under 18 years whose household income is at or below 138% of the federal poverty level (FPL).
Women who are pregnant with a household income below 138% of the FPL.
People who receive Supplemental Security Income (SSI).
Parents who earn an income that falls under the state’s eligibility for cash assistance.
States may also choose to provide Medicaid coverage to other, less well-defined groups who share some characteristics of the above.

These groups may include:

Pregnant women, children, and parents earning income above the mandatory coverage limits.
Some adults and older adults with low incomes and limited resources.
People who live in an institution and have low income.
Certain adults who are older, have vision loss or another disability, and an income below the FPL.
Individuals without children who have a disability and are near the FPL.
“Medically needy” people whose resources are above the eligibility level their state has set.
Medicaid does not provide medical assistance to all people with low income and low resources.

The Affordable Care Act of 2012 gave states the option to expand their Medicaid coverage. In the states that did not expand their programs, several at-risk groups are not eligible for Medicaid.

These include:

Adults over 21 years who do not have children and are pregnant or have a disability.
Working parents with incomes below 44% of the FPL
Legal immigrants in their first 5 years of living in the U.S.

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What is Medicare?
Medicare is a federal health insurance program that funds hospital and medical care for older people in the U.S. Some people with disabilities also benefit from Medicare.

The program consists of:

Part A and Part B for hospital and medical insurance
Part C and Part D that provide flexibility and prescription drugs
Medicare Part A
Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays and other services.

In the hospital, this includes:

meals
supplies
testing
a semi-private room
It also pays for home healthcare, such as:

physical therapy
occupational therapy
speech therapy
However, these therapies must be on a part-time basis, and a doctor must consider them medically necessary.

Part A also covers:

care in a skilled nursing facility
walkers, wheelchairs, and other medical equipment for older people and those with disabilities
Payroll taxes cover the costs of Part A, so it is not usually compulsory to pay a monthly premium. Anyone who has not paid Medicare taxes for at least 40 quarters will need to pay the premium.

In 2020, people who have paid the tax for less than 30 quarters will need to pay a $458 premium. A $252 premium will apply to those who have paid for 30–39 quarters.

Medicare Part B
Medicare Part B, or Supplementary Medical Insurance (SMI), helps pay for specific services.

These services include:

medically necessary doctor’s visits
outpatient hospital visits
home healthcare costs
services for older people and those with a disability
preventive care services
For example, Part B covers:

durable medical equipment, such as canes, walkers, scooters, and wheelchairs
doctor and nursing services
vaccinations
blood transfusions
some ambulance transportation
immunosuppressive drugs after organ transplants
chemotherapy
certain hormonal treatments
prosthetic devices
eyeglasses
For Part B, people must:

pay a monthly premium, which was $144.60 per month, as of 2020
meet an annual deductible of $198 a year before Medicare funds any treatment
Premiums might be higher, depending on the person’s income and current Social Security benefits.

After meeting the deductible, most people on a Medicare plan will need to pay 20% of costs approved by Medicare for many doctor services, outpatient therapist treatment, and durable medical equipment.

Enrollment in Part B is voluntary.

Medicare Part C
Medicare Part C, also known as Medicare Advantage Plans or Medicare+ Choice, allows users to design a custom plan that suits their medical situation more closely.

Part C plans provide everything in Part A and Part B, but may also offer additional services, such as dental, vision, or hearing treatment.

These plans enlist private insurance companies to provide some of the coverage. However, the details of each plan will depend on the program, and the eligibility of the individual.

Some Advantage Plans team up with HMOs or preferred provider organizations (PPOs) to deliver preventive healthcare or specialist services. Other plans focus on people with specific needs, such as individuals living with diabetes.

Medicare Part D
This prescription drug plan was a later addition in 2006. Several private insurance companies administer Part D.

These companies offer plans that vary in cost and cover different lists of drugs.

To participate in Part D, a person must pay an additional fee called the Part D income-related monthly adjustment amount. The fee depends on the person’s income.

Many people’s Social Security checks will deduct the premium. Others will, instead, get a bill directly from Medicare.

Services that Medicare does not provide
If Medicare does not cover a medical expense or service, a person may wish to take out a Medigap plan for supplemental coverage.

Private companies also offer Medigap plans. Depending on the individual plan, Medigap may cover:

copayments
coinsurances
deductibles
care outside of the U.S.
If a person has a Medigap policy, Medicare will first pay their eligible portion. Afterward, Medigap will pay the rest.

To have a Medigap policy, a person must have both Medicare Parts A and B and pay a monthly premium.

Medigap policies do not cover prescription drugs, which a Part D plan covers.