Do I Qualify for Medicare or Medicaid?

People living with obesity often face high healthcare costs. Paying for medical care, including hospital visits, specialist consultations, and prescription drugs, can be costly.

Health insurance in the United States is especially complicated and can be expensive. Medicare and Medicaid are two government programs that provide coverage to millions of Americans. Learning about these programs can help you afford the obesity healthcare you need.

How does Medicare work?

Medicare is a federal health insurance program for people 65 or older and younger people with disabilities. Different parts of Medicare cover specific services:¹

• Part A: Covers hospital stays, nursing facility care, hospice care, and some home care.
• Part B: Covers certain doctors’ services, medical supplies, and preventive services—including obesity screening and behavioral counseling.
• Part D: Helps cover the cost of prescription drugs.

Most people do not pay premiums for Part A, but have to pay the standard Part B premium amount, which is usually automatically deducted from Social Security benefits. Part D plans vary in cost and coverage.¹ When you first enroll in Medicare, you can choose how to get coverage. Talk to your doctor or a Medicare representative for help in choosing a plan that is right for you.

How do I know if I am eligible for Medicare?

If you are 65 or older, you are eligible for Medicare. If you are under 65 and have a disability, you get Part A and Part B after receiving Social Security Disability Insurance (SSDI) for two years.²

Having obesity does not automatically qualify you for SSDI benefits. In order to qualify, your health condition must prevent you from working. Some factors that help determine if you are eligible for SSDI include severe functional limitations or complications from comorbidities such as:³

• Severe cardiovascular disease
• Advanced osteoarthritis of weight-bearing joints
• Severe respiratory disorders like sleep apnea

Even if you do not meet these criteria, there are other ways to be approved for SSDI benefits.

How does Medicaid work?

Medicaid provides healthcare coverage for low-income adults, children and their parents, pregnant women, and people with disabilities. Unlike Medicare, which is managed by the federal government, Medicaid is run by individual states. Many people with obesity get health insurance from Medicaid programs, but coverage for weight loss medications and bariatric surgery varies significantly by state.^4,5

Contact your state Medicaid agency for more information and to find out what Medicaid coverage looks like in your state.

The Children’s Health Insurance Program (CHIP) provides coverage to children in families with incomes too high for Medicaid but too low to afford private insurance. CHIP is also run by individual states.⁶

How do I know if I am eligible for Medicaid?

Each state has its own guidelines to decide if you are eligible for Medicaid or if your child is eligible for CHIP. Contact your state Medicaid agency to find out if you are eligible for CHIP.

If you have too much income to qualify, some states let you “spend down” to become eligible. This lets you subtract your medical expenses from your income. Talk to your state Medicaid program to determine if this applies in your state. Even if you do not qualify based on income, you should still apply in case you qualify for any other state programs.⁵

If you are eligible for Medicare and full Medicaid coverage, most of your healthcare costs will be covered. Medicare will pay for services first, and Medicaid will then cover certain things that Medicare does not.⁵

How do I apply for Medicare or Medicaid?

When you first become eligible for Medicare, you have seven months to enroll. This period begins three months before the month you turn 65 and ends three months after the month you turn 65. If you do not sign up when you first become eligible, you can sign up between January 1 and March 31 each year. You may also qualify for a “special enrollment period” after you become eligible if your insurance through an employer ends.⁷

If you are turning 65 in the next three months and are not already getting SSDI benefits, you will not get Medicare automatically. You will first need to sign up for Social Security. Then, Medicare will send you information about how to enroll and what decisions you need to make. If you are turning 65 in the next three months and already get SSDI benefits, you will get Medicare automatically when you become eligible.²

For Medicaid, you can apply either through the Health Insurance Marketplace or through your state Medicaid agency. The Health Insurance Marketplace will send your information to the state agency and contact you about enrollment. You can apply for Medicaid at any time of the year.