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How Does Medicare and Medicaid Work Together?

  • Enroll in a Medicare Advantage DUAL PLAN
  • Find the Perfect Health Insurance Plan

When you qualify for Medicare and Medicaid, you are dual-eligible. Dual-eligibility allows beneficiaries to combine Medicare and Medicaid benefits to expand coverage and assist with costs. It is not a separate plan.

Most seniors qualify for Medicare at age 65. Some seniors on a fixed income also qualify for Medicaid due to low income or limited resources. An individual under 65 receiving Social Security Disability Insurance can have Medicaid and later enroll in Medicare after 24 months of receiving Social Security Disability benefits, or upon reaching the age of 65.

Medicaid benefits cover additional costs outside of Medicare coverage, and some benefits not covered by Medicare.

What’s the difference between Medicaid and Medicare?

Medicaid is an assistance program. For anyone that qualifies, Medicaid enrollment is open the entire year. Most Medicaid enrollees lack access to affordable quality health insurance. Medicaid patients usually do not pay the costs of covered medical services. When it’s time to enroll in Medicaid, it is essential to know your state-level program follows federal guidelines for standard coverage but may have expanded coverage.

Medicare is a public health insurance program. Most people that use Medicare are 65 years of age or older. Patients pay part of their medical costs through deductibles and premiums. Medicare is a federal program and is administered the same nearly everywhere in the  United States. Medicare enrollment is available at specific times during the year, including Initial Enrollment,  Annual Enrollment Period (AEP), Medicare Advantage Open Enrollment (OEP), and  Special Election Periods (SEP).

Can You Have Medicare and Medicaid?

If you receive coverage from both Medicaid and Medicare, you’re a “dually eligible beneficiary.” If you are dual-eligible, you may be enrolled in Medicare and then qualify for Medicaid, or enroll first in Medicaid but later qualify for Medicare. Medicaid assists low-income seniors, and people with disabilities also enrolled in Medicare.

How does dual eligibility work?

Dual-eligible beneficiaries can have:

  • Medicare Part A
  • Medicare Part B
  • Both Part A and Part B
  • Full Medicaid benefits
  • State Medicare Savings Programs

Medicare benefits always pay first, and Medicaid benefits assist with costs not fully covered by Medicare.

Medicaid will pay premiums and out-of-pocket expenses for dual-eligible Medicare beneficiaries. Medicare and Medicaid work together to cover costs, including long-term services. If you do not have full Medicaid benefits, Medicare Savings Programs (MSP) may help cover some of those costs:

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) program
  • Qualifying Individual (QI) Program
  • Qualified Disabled and Working Individuals (QDWI) Program

Medicaid may also cover prescription drugs, eyeglasses, and hearing aids. Medicaid covers any qualified medical costs not covered by Medicare up to your state’s payment limit. A GoHealth licensed insurance agent can help you navigate enrollment, identify available subsidies, and find the right coverage. You may also find information on your state’s Medicaid website.

What is Covered?

Your state determines Medicaid services. Original Medicare coverage includes Part A (hospital) and Part B (medical). It is important to know that your state government sets the rules, regulations, and policies for Medicaid within federal guidelines. Federally administered Medicare Part A and Part B coverage is standardized for all beneficiaries throughout the United States.

Your Medicare Part A and Part B benefits do not change with dual-eligibility, but the level of Medicaid coverage may vary. Whether you qualify for “partial” or “full” dual eligibility depends on your income and assets. Partial coverage may include Medicaid coverage for expenses like Medicare premiums for Part A and Part B , deductibles, and co-insurance. Full coverage consists of the same benefits as partial coverage and may include services not covered by Medicare like long-term care.

What Are My Costs with Dual-Eligibility?

Dual-eligibility can limit individual costs for beneficiaries. For those with Medicare, state Medicaid programs will pay for many cost-sharing and out-of-pocket expenses for medical services. For any service you receive, Medicare pays first and covers all eligible costs. Any qualified costs not covered by Medicare will be covered by Medicaid.

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