Medicare and Medicaid are separate programs with different eligibility rules. Medicare is primarily based on age or disability, while Medicaid is based on income. Some people qualify for both at the same time, which provides the most comprehensive coverage available through government health insurance.
How You Qualify for Medicare
Medicare eligibility comes down to two main paths: turning 65 or having a qualifying disability. Most people get premium-free Medicare Part A (hospital coverage) by reaching age 65 and having enough work history. Specifically, you or your spouse need to have paid Medicare payroll taxes during your working years, earning what Social Security calls “quarters of coverage.” If you’re already receiving Social Security or Railroad Retirement Board benefits at 65, enrollment is automatic.
Part B, which covers doctor visits and outpatient care, is available to everyone who qualifies for Part A. It carries a standard monthly premium of $185 in 2025. Higher earners pay more: if your individual income exceeds $106,000 (or $212,000 for joint filers), your monthly premium rises in tiers, reaching as high as $628.90 for individuals earning $500,000 or more.
Medicare Before Age 65
If you receive Social Security disability benefits, you become eligible for Medicare after 24 months of receiving those benefits. There is one notable exception: people diagnosed with ALS (Lou Gehrig’s disease) get Medicare automatically as soon as disability benefits begin, with no waiting period. People with end-stage renal disease also have a separate pathway to immediate eligibility.
How You Qualify for Medicaid
Medicaid eligibility is based on your household income measured against the federal poverty level (FPL). The specifics depend heavily on which state you live in, because states set their own Medicaid rules within federal guidelines. The most significant factor is whether your state has expanded Medicaid under the Affordable Care Act. As of late 2023, 40 states plus Washington, D.C. have done so.
In expansion states, most adults with household income up to 138% of the federal poverty level qualify. For 2025, that translates to roughly $21,597 for an individual or $44,367 for a family of four. In states that haven’t expanded Medicaid, eligibility for adults is far more restrictive. You may need to fall below 100% FPL and also belong to a specific category, such as being pregnant, having a disability, or caring for dependent children.
The 2025 federal poverty guidelines set the baseline at $15,650 for a single person and $32,150 for a family of four in the 48 contiguous states. Each additional household member adds $5,500.
Asset Limits and Exemptions
Some Medicaid programs also count your assets, not just your income. Programs that use the Modified Adjusted Gross Income (MAGI) method, which covers most working-age adults and children, do not count resources at all. But programs for older adults, people with disabilities, and long-term care applicants typically do. In those cases, limits can be quite low. Pennsylvania, for example, sets resource limits for its full-benefit Medicaid at $2,000 for a single person and $3,000 for a married couple. Other states set their own thresholds, but the general pattern is similar: modest limits with exemptions for things like a primary home and one vehicle.
The Spend-Down Option
If your income is too high for Medicaid but you have significant medical expenses, some states offer a “spend down” pathway. The concept works like a deductible: you pay the difference between your income and your state’s Medicaid income limit out of pocket on qualifying health expenses. Once you’ve spent that amount, Medicaid kicks in for the rest of the spend-down period, which ranges from one to six months depending on the state.
Qualifying expenses include medications, paid and unpaid medical bills, nursing home care, health-related home modifications like wheelchair ramps, and transportation to medical appointments. These programs sometimes go by names like “excess income program” or “medically needy program,” and some states restrict them to people who are 65 or older, blind, or have a disability.
Qualifying for Both Programs at Once
About 12 million Americans are “dual eligible,” meaning they have both Medicare and Medicaid simultaneously. This happens when someone meets Medicare’s age or disability requirements and also has income low enough to qualify for Medicaid. Dual eligibility is valuable because Medicaid can cover costs that Medicare doesn’t, including long-term nursing home care, dental and vision services, and Medicare premiums and copays.
The federal government recognizes several categories of dual eligibility, each with different income thresholds and benefits:
- Qualified Medicare Beneficiary (QMB): Income at or below 100% FPL. Medicaid pays your Medicare premiums, deductibles, and copays. Resource limits are $9,660 for an individual and $14,470 for a couple in 2025.
- Specified Low-Income Medicare Beneficiary (SLMB): Income between 100% and 120% FPL. Medicaid pays your Part B premium. Same resource limits as QMB.
- Qualifying Individual (QI): Income between 120% and 135% FPL. Medicaid pays your Part B premium. Same resource limits apply, and you cannot otherwise be eligible for Medicaid.
- Full Benefit Dual Eligible (FBDE): People who qualify for Medicare and also meet their state’s criteria for full Medicaid benefits. This often includes recipients of Supplemental Security Income (SSI) or people who qualify through medically needy or institutional care pathways.
In practical terms, if you’re 65 or older with very limited income, you likely qualify for at least one of these categories. QMB status is particularly important because it prohibits doctors and hospitals from billing you for Medicare cost-sharing, effectively eliminating most out-of-pocket costs.
How to Apply
Medicare enrollment happens through Social Security. If you’re already collecting Social Security benefits at 65, you’re enrolled automatically. Otherwise, you can sign up at ssa.gov or at your local Social Security office during a seven-month window around your 65th birthday (three months before, your birthday month, and three months after).
Medicaid applications go through your state’s Medicaid agency, and you can apply through your state’s website, at HealthCare.gov, by phone, or in person. Processing times vary by state but typically take 30 to 45 days. If you think you qualify for both programs, apply for each one separately since they’re administered by different agencies. Your state Medicaid office can also screen you for Medicare Savings Programs like QMB or SLMB if you already have Medicare and want help with costs.