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Comparing Private Health Insurance, Medicare and Medicaid

July 29, 2016
Finding Health Insurance, Health
compare-medicare-medicaid-health-insurance
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If you’re looking for health insurance, there are four main ways you can get coverage: through an employer in a group plan, in a private plan, or through the government programs of Medicare or Medicaid.

As of 2014, the most recent year for which data are available, about 49% of Americans have insurance through an employer, according to the Kaiser Family Foundation. Another 34% have coverage through government programs, and about 6% have non-employer-based private health plans, such as those purchased through the federal marketplace, Healthcare.gov.

About 10% of Americans were uninsured in 2014, according to the foundation. That number is declining in large part because of the Obamacare penalty for going uninsured, enacted in 2014. As more Americans gain health coverage, questions arise about the ways these different kinds of insurance can overlap.

Comparing private insurance, Medicare and Medicaid

 Private individual health plansEmployer-sponsored plansMedicareMedicaid
DescriptionInsurance you buy on an exchange, such as Healthcare.gov or a state exchange, or directly from a health insurance company.Insurance you buy through an employer that must meet certain coverage and affordability metrics set forth by the federal government.The federally funded health program covering adults with disabilities, those over age 65, and people with end-stage renal disease, or kidney failure.The joint health program run by states and the federal government that covers kids and adults with low incomes or limited means to pay for health care.
Who is eligibleAll U.S. citizens except Medicare and Medicaid recipients.Anyone working for an employer that offers health insurance, and usually their dependents.Adults over 65, with certain disabilities, or with end-stage renal disease.Low-income adults and children.
% of people with this type of plan6%49%13%19%
PremiumsHigher premiums overall, often offset by tax credits. Premiums often subsidized by employer, must be “reasonably affordable.”Medicare Part A free; low premiums for other parts.No or very low premiums.
Out-of-pocket maximum in 2016$6,850 per person or $13,700 per family, for marketplace plans.$6,850 per person or $13,700 per family.No limit.Based on income.

Other government health insurance programs

  • Tricare: Health insurance provided to active or retired military service members and their families, operated by the U.S. Department of Defense.
  • Veterans Affairs coverage: Health insurance and care provided to veterans and some retired military service members, operated by the U.S. Department of Veterans Affairs.

If you have Tricare or VA benefits, you can get personalized advice. Contact Tricare customer service or Veterans Affairs to speak directly with someone who can answer your questions.

You may be able to enroll in two types of health plan

Some types of health insurance plans can overlap, and some can’t. Here are the rules of overlapping coverage:

  • You can have Medicaid and Medicare at the same time.
  • You can’t have Medicaid along with any type of private insurance.
  • Medicare can overlap with employer-sponsored health insurance, but not with plans sold on the federal or state marketplaces.
  • Most private insurance plans may overlap with one another, but you can’t get subsidies on the exchanges to reduce premiums if your employer offers an affordable plan.

Lacie Glover is a staff writer at NerdWallet, a personal finance website. Email: lacie@nerdwallet.com. Twitter: @LacieWrites.