When navigating the realm of senior benefits, two of the most important—and most
confused—topics are Medicare and Medicaid. The programs are not interchangeable and cover
very different needs. Medicare focuses on your immediate medical and short-term hospital
needs, while Medicaid acts as the primary safety net for seniors needing long-term skilled
nursing care. As we will discuss below, Medicare covers things like prescription drugs and
doctor visits, but it does not cover long-term skilled nursing care.
What Is Medicare?
Medicare is designed to provide healthcare stability for the following individuals:
● People 65 or older
● Younger people with specific disabilities
● Individuals with end-stage renal disease (permanent kidney failure)
Medicare is a federal entitlement program that you have typically paid into through your working
life. It is available to almost everyone 65 or older regardless of how much money they have. It
provides a core level of support for seniors, but it is not a catchall. What most people do not
realize is that Medicare does not cover long-term skilled nursing care.
To better understand what Medicare covers, we must look at each of its “parts.”
Understanding the Parts of Medicare
The Medicare program is divided into four main parts, each addressing different aspects of
healthcare. Here is a breakdown of what you can expect each to cover, along with projected key
costs for 2026.
Medicare Part A: Hospital Insurance
Part A is designed to cover acute, inpatient needs. After you have paid a $1,736 deductible per
benefit period, it covers the following services:
● Inpatient hospital care (does not cover patients in observation status)
● Short-term skilled nursing facility care (copays up to 100 days)
● Hospice care
● Limited home healthcare
Medicare Part B: Medical Insurance
Part B is where you will find coverage for your outpatient needs—the services you use most
frequently.
● What it covers
○ Doctor visits
○ Outpatient care
○ Preventive services (vaccines, screenings)
○ Durable medical equipment (wheelchairs, walkers, etc.)
● Key costs (2026)
○ Monthly premium: $202.90 (may be higher based on income)
○ Annual deductible: $283
○ Coinsurance: Generally 20 percent of Medicare-approved costs
Medicare Part C: Medicare Advantage
Medicare Part C, commonly known as Medicare Advantage, is effectively a private version of
Medicare. Instead of the federal government paying your doctors directly, they pay a private
insurance company to manage your care. It combines Parts A, B, and often D and offers other
benefits like vision, dental, and hearing, which are not found in traditional Medicare. Typical
network rules apply, so you will have to ensure that your preferred providers are in network with
your insurance company before you purchase Part C. These plans also require your provider to
seek prior authorization from the insurance company before you have certain surgeries, MRIs,
or specialized treatments.
Medicare Part D: Prescription Drugs
Medicare Part D offers coverage for certain outpatient prescription drugs. This year, the amount
Medicare Part D beneficiaries pay for covered prescriptions is capped at $2,100—a significant
and beneficial change from prior years. Part D is managed by private companies that charge
monthly premiums and enforce deductibles (up to $615 in 2026).
What Medicare Does NOT Cover
The single biggest misconception about Medicare is what it covers when it comes to long-term
care. Remember this: MEDICARE DOES NOT COVER LONG-TERM CARE. If you need a
nursing home for months or years (beyond the short-term skilled care covered by Part A),
Medicare will not pay. This is where Medicaid comes in.
If you are looking for assistance with these costs, you must consider other options, like Medicaid
or private long-term care insurance.
What Is Medicaid?
Medicaid is a joint federal and state program that provides health coverage to millions of
Americans. Most relevantly, Medicaid covers the cost of long-term skilled nursing care for
people who need it and meet the program’s financial eligibility requirements.
What Long-Term Care Medicaid Covers
Long-term Medicaid provides a broad range of health services, including those not covered by
Medicare, most notably:
● Long-term care. Medicaid is the largest payer for long-term care services in the country,
covering both nursing home care, assisted living care, and home- and community-based
services (HCBS) that help individuals stay in their homes.
● Inpatient and outpatient hospital services
○ Doctor and clinic services
○ Prescription drugs (Medicaid can help cover Part D premiums and copays for those
eligible for both, known as dual eligibles).
○ Vision, dental, and hearing (coverage varies significantly by state, unlike Medicare
Advantage).
Eligibility Requirements for Long-Term Care Medicaid
Medicaid eligibility for those needing long-term care is complex and determined primarily at the
state level, but it generally includes the following:
● Financial limits (income and resources). Both your income and your total countable
assets (like savings, but typically excluding your primary home and car) must fall below
certain limits. These limits vary by state and by specific Medicaid eligibility categories (e.g.,
elderly, disabled).
● Category. You must fit into a recognized category, such as being aged 65 or older, blind, or
disabled.
● Residency and citizenship. You must be a resident of the state in which you are applying
and a US citizen or an eligible noncitizen.
Navigating Medicaid eligibility requires careful planning with an attorney. With guidance, you
may be able to preserve your home and other assets for those you love and qualify for
assistance under the Medicaid program. If you are concerned about how you will pay for long-
term care in the future, contact us so that we can help you determine your options.