Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
How Medicaid Works with Medicare
Many of the millions of Medicare enrollees in the United States are at least 65 years old; however, Medicare is also available to younger people with qualifying disabilities. You may also be eligible for Medicaid if you meet income and resource limit requirements.
How claims work
Medicaid always pays last. In other words, it doesn’t pay anything toward your medical expenses until Medicare, a group insurance plan, and a Medicare Supplement Insurance Plan (Medigap) have paid their portions of the bill. For this reason, Medicaid is known as the “payer of last resort.”
Any time you receive a Medicare-approved service, the provider files a claim with Medicare. Once Medicare pays its share, the provider can file a claim with secondary insurance providers, such as an employer-sponsored insurance plan or Medigap plan. Finally, once all those insurers have paid their share of the bill, Medicaid pays its share. This applies to various services, including hospital care, laboratory tests, X-rays, and doctor visits. If you’re injured in an accident, Medicaid may require a liability insurer or a workers’ compensation plan to cover some of the costs before paying out on a claim.
How much do you have to pay?
For beneficiaries with dual eligibility, most health care costs are covered by Medicare and Medicaid, including the monthly premiums for Original Medicare and Medicare Advantage Plans. Original Medicare provides basic inpatient and outpatient medical care, but it doesn’t cover prescriptions.
As an alternative to Original Medicare, Medicare Advantage Plans often cover extra services, such as dental cleanings and eye exams for glasses. Most Medicare Advantage Plans also include prescription coverage. Dual-eligible beneficiaries will automatically qualify for Extra Help paying for Medicare drug coverage (Part D). Medicare Part D is a supplemental prescription drug plan often purchased with Original Medicare to ensure coverage of medication costs.
If you need a medication that Medicare doesn’t cover, Medicaid may cover some of the costs. Total out-of-pocket costs for a dual-eligible individual depends on several factors, including the type of plan selected (Original Medicare or Medicare Advantage) and whether you need a Part D supplement.
Can you get help with payments?
Medicare beneficiaries with income and financial resources below a certain threshold may get help from Medicaid to pay Medicare premiums and other out-of-pocket costs. Several forms of assistance are available, including the Qualified Medicare Beneficiary program, the Specified Low-Income Beneficiary program, state Medicare Savings Programs, and the Qualifying Individual program.
Medicaid may also make Medicare coverage more affordable by paying for certain services that Medicare doesn’t cover. For example, Medicare doesn’t typically cover eyeglasses or hearing aids. Still, Medicaid may cover some or all of the cost of these items. Medicaid may also cover more than 100 days of care in a skilled nursing facility. In comparison, Medicare only pays for a maximum of 100 days of this type of care per benefit period. Eligibility for these programs depends on your income, assets, and eligibility for other savings programs run by government agencies and nonprofit organizations.
2021 Dual Eligible Standards
Medicare is available if you’re at least 65 years old or have some disability, such as amyotrophic lateral sclerosis, that qualifies you for Social Security Disability Income (SSDI) benefits. To receive premium-free Part A coverage, you must have worked and paid Medicare taxes for a minimum number of quarters. You must also be a U.S. citizen or lawful permanent resident.
Medicaid is also available to U.S. citizens and lawful permanent residents. However, there are some income and financial resource limits in addition to the other eligibility requirements. Financial eligibility is determined based on your modified adjusted gross income (MAGI). Some applicants are exempt from the MAGI requirements, such as individuals who are blind or disabled. To be dual-eligible, you must meet the basic Medicare requirements and the income and resource requirements for Medicaid.
|Medicare||65+ or younger with a qualifying disability||
||$350 to $2,402 depending on the state of residence and type of Medicaid coverage (e.g., regular Medicaid, nursing home Medicaid, Medicaid for aged, blind, and disabled, etc.)||$1,500 to $10,000 (single)
$1,500 to $15,000 (married) if both spouses are applying for coverage
$1,500 to $130,800 for the non-applicant spouse if only one spouse is applying
|Medicare and Medicaid||65+ or younger with a qualifying disability or medical condition||
* Except in Alaska and Hawaii
Qualified Medicare Beneficiary (QMB)
The Qualified Medicare Beneficiary program offers the most assistance with Medicare out-of-pocket costs. You may receive help paying your Part A and/or Part B premiums, copayments, coinsurance, and deductibles. For example, under the QMB Only Without Other Medicaid program, Medicaid pays Part A and part B premiums and copays, coinsurance, and deductibles for Medicare-approved services. The monthly income limit is 100% of the federal poverty level (FPL) plus $20.
QMB Plus offers an additional level of coverage by giving eligible beneficiaries full Medicaid coverage in addition to assistance with their Medicare premiums, deductibles, copays, and coinsurance. QMB Plus requires you to qualify for both full Medicaid and QMB. You must also have no more than three times the SSI resource limit.
2021 Dual Eligible Standards for QMB in all states and D.C. except Alaska and Hawaii:
In Alaska: $1,361/$1,835, in Hawaii: $1,255/$1,690
Specified Low-Income Medicare Beneficiary (SLMB)
The Specified Low-Income Medicare Beneficiary program also has two options, SLMB Without Other Medicaid and SLMB Plus. The SLMB program covers fewer Medicare expenses than the QMB program because it has higher income limits. SLMB Without Other Medicaid is available to applicants with incomes between 100% and 120% of the FPL. You must also be enrolled in Medicare Part A and have no more than three times the SSI limit in financial resources. In addition, the SLMB Without Other Medicaid program pays your Medicare Part B premiums.
The SLMB Plus program covers Part B premiums and offers full Medicaid coverage to enrollees. To qualify for SLMB Plus, you must meet the complete Medicaid requirements in addition to meeting the income and resource requirements for the SLMB Without Other Medicaid program.
2021 Dual Eligible Standards for SLMB in all states and D.C. except Alaska and Hawaii:
In Alaska: $1,629/$2,197, in Hawaii: $1,502/$2,024
Qualifying Individual (QI)
Under the Qualifying Individual program, Medicaid pays your Medicare Part B premiums. The QI program is different from the QMB and SLMB programs because it’s only available on a first-come, first-served basis. Another difference is you must apply for QI coverage every year; however, enrollees who received QI benefits the previous year are given priority. You can’t get QI benefits if you qualify for Medicaid.
The QI income limit is slightly higher than the limit for the SLMB program: 120% to 135% of the FPL. QI beneficiaries are also capped at no more than three times the SSI resource limit. Unlike many other Medicare Savings Plans, the QI program is administered by individual states, not the federal government. If you’re interested in the QI program, contact your state Medicaid program for information on applying.
2021 Dual Eligible Standards for QI in all states and D.C. except Alaska and Hawaii:
In Alaska: $1,831/$2,470, in Hawaii: $1,688/$2,275
Qualified Disabled and Working Individuals (QDWI)
The Qualified Disabled and Working Individuals Program helps pay Medicare Part A premiums for eligible individuals. To qualify for the QDWI program, you must be under 65, have a disability, and meet the income and resource requirements. You can’t be on state medical assistance and must have lost your premium-free Part A coverage and SSDI benefits because you decided to return to work.
At up to 200% of the FPL, the income limit for the QDWI program is much higher than the QMB, SLMB, and QI programs. You may also have up to two times the SSI limit in financial resources. In addition, enrollees who qualify for QDWI aren’t eligible for other Medicaid benefits.
2021 Dual Eligible Standards for QDWI in all states and D.C. except Alaska and Hawaii:
In Alaska: $5,449/$7,342, in Hawaii: $5,025/$6,765
Qualifying and Applying for Medicare and Medicaid
The Medicare eligibility requirements can be confusing, especially for applicants under 65 who get Medicare coverage for a qualifying disability. Area Agencies on Aging have trained counselors on hand to answer questions about Medicare and help current Medicare beneficiaries determine if they might be dually eligible. AAA counselors can also help you determine if you’re eligible for the QMB, SLMB, QI, or QDWI programs.
Some communities have geriatric care managers available to assist. A geriatric care manager is a registered nurse or social worker who has been trained to help older adults access health and social services. In addition, elder care attorneys, State Health Insurance Assistance Program counselors, and commission-based Medicaid planners are also good resources for information on Medicaid eligibility and benefits.
When income exceeds the limit
Some states offer spend-down programs to help individuals whose incomes exceed the Medicaid limits. This type of program allows you to deduct certain medical expenses from your income, making it possible to qualify for certain types of Medicaid. For example, some states require you to submit receipts documenting your medical expenses. Others allow you to pay a monthly premium representing the difference between your income and the Medicaid income limit. Other spend-down requirements are up to each state.
When assets exceed the limit
When assets exceed the limit, it may be possible to “spend down” those assets until the individual becomes eligible for Medicaid coverage. However, use caution when using this approach. Almost every state has a five-year lookback period in which officials can examine a Medicaid applicant’s asset transfers. If you violate the rules, the state can impose a period of Medicaid ineligibility. Nevertheless, some transactions are permitted, such as modifying a home to make it more accessible or purchasing medical items that aren’t covered by insurance.
As long as they cover mandatory benefits required by CMS, states can implement cost-sharing arrangements as part of their Medicaid plans. CMS caps out-of-pocket costs, but state Medicaid programs are also allowed to charge a premium for enrollees in the following groups:
- Pregnant women with household incomes at or above 150% of the (Federal Poverty Level (FPL)
- Infants with household incomes at or above 150% of the FPL
- Medically needy individuals
- Disabled individuals who are eligible for Medicaid due to the Family Opportunity Act
- Qualified disabled individuals who work and have incomes above 150% of the FPL
- Disabled individuals who are employed under the Ticket to Work and Work Incentives Improvement Act of 1999
States also have the right to classify prescription medications as preferred or nonpreferred and charge different copays for each type. For people whose incomes are below 150% of the FPL, copays for nonpreferred drugs are limited to small amounts. If a Medicaid beneficiary has an income exceeding 150% of the FPL, the nonpreferred copay may be as much as 20% of the cost of the drug. States are also allowed to charge different copay amounts for generic and brand-name drugs.
Although emergency care is typically exempt from all out-of-pocket charges, a state’s Medicaid program can decide to charge a copay for non-emergency use of the emergency department. The copayment can only be charged if a health professional determines that you don’t need emergency care. An alternative care provider must also be available to care for you promptly.
The federal government and individual states work together to ensure that individuals with low incomes have access to basic health coverage under the Medicaid program. Because the federal government distributes funds to the states, the Centers for Medicare & Medicaid Services, a federal agency, has standards that every state Medicaid program must meet. It’s up to individual states to decide if they want to offer additional services.
CMS’s Mandatory benefits include hospital care, laboratory tests, radiology services, home health services, and care provided by a primary care physician or other medical specialists. CMS also requires each state to cover a certified family nurse practitioner, a nurse-midwife, or a certified pediatric nurse practitioner. In addition, states that decide to offer more than the minimum level of coverage may pay for physical therapy, prescription drugs, occupational therapy, and case management.
Medicaid also covers some services that aren’t covered by Medicare, which benefits persons with dual eligibility. For example, Medicaid may cover medical transportation, personal care assistance, chore services, housekeeping, medication administration services, meal delivery, and in-home nursing care. However, not all optional services are available in all states, so it’s important to check with Medicaid before signing up with a new health care provider or hiring someone to perform in-home care. Some states cover only mandatory benefits while other states pay for extras like prosthetics, dentures, chiropractic care, podiatry, and private duty nursing.
How to Apply
Contact your local Medicaid office to ask questions about program requirements and request a paper application. In many states, it’s also possible to apply for Medicaid coverage on HealthCare.gov. If you aren’t eligible for Medicaid, it may be possible to get a tax credit to help pay for a plan from the Health Insurance Marketplace. HealthCare.gov asks for the names, birth dates, and Social Security numbers of all household members, so it’s important to have this information on hand before beginning the application process. You should also have your pay stubs or W-2s on hand to help with questions related to household income.
- State Health Insurance Assistance Programs: Connect with an experienced counselor who can offer unbiased advice on Medicare and Medicaid options.
- National Association for Area Agencies on Aging: Search for an Area Agency on Aging by city, state, or ZIP code.
- National Academy of Elder Law Attorneys: Find an experienced elder care attorney to help with Medicare/Medicaid eligibility issues.
- Medicare Interactive: Use this independent reference tool to find information on Medicare-covered services, Original Medicare vs. Medicare Advantage, and other relevant topics.
- Medicare Resource Center: Get answers to common questions about Medicare from the experts at AARP.
- American Council on Aging: Learn more about how to use Medicaid to cover long-term care costs.
- The National Long-Term Care Ombudsman Resource Center: Find out what a long-term care ombudsman can do to help resolve complaints related to nursing homes and other long-term care facilities.
- Center for Health Care Strategies: Access information on Medicaid and learn how to get help from a local charity care program.
- Medicare.gov: Find information on Original Medicare, Medicare Advantage, Medicare Part D drug coverage, and Medicare Supplement Insurance, along with links to an online application and local resources.
- Family Caregiver Alliance: Use the free CareNav tool to connect with a staff member who can direct you to resources in your area.
- Senior Medicare Patrol: Learn how to protect yourself or a loved one against Medicare fraud.
Learn More From Our Sources
- Medicare.gov | Getting Medicare if you have a disability | Last accessed July 2021
- Medicare.gov | I have End-Stage Renal Disease (ESRD) | Last accessed July 2021
- Medicare.gov | Medicaid | Last accessed July 2021
- Medicare Interactive | How Medicaid works with Medicare | Last accessed July 2021
- CMS.gov | Deficit Reduction Act Important Facts for State Policymakers | Last accessed July 2021
- Medicare.gov | What’s Medicare? | Last accessed July 2021
- Medicare.gov | Medicare Savings Programs | Last accessed July 2021
- Medicaid.gov | Eligibility | Last accessed July 2021
- MACPAC | People with disabilities | Last accessed July 2021
- American Council on Aging | Medicaid eligibility income chart by state – updated Mar. 2021 | Last accessed July 2021
- American Council on Aging | State-specific Medicaid eligibility requirements | Last accessed July 2021
- CMS.gov | Dually Eligible Beneficiaries Under Medicare and Medicaid | Last accessed July 2021
- National Council on Aging | Medicaid and Medicare Savings Programs | Last accessed July 2021
- n4a | National Association for Area Agencies on Aging | Last accessed July 2021
- National Institute on Aging | What Is a Geriatric Care Manager? | Last accessed July 2021
- National Council on Aging | Medicaid Planners: Pros & Cons of Public and Private Assistance | Last accessed July 2021
- Medicare Interactive | Spend-down program for beneficiaries with incomes over the Medicaid limit | Last accessed July 2021
- National Council on Aging | Spending Down Assets to Become Medicaid Eligible for Nursing Home/Long Term Care | Last accessed July 2021
- Medicaid.gov | Cost Sharing | Last accessed July 2021
- Paying for Senior Care | List of State Medicaid Offices | Last accessed July 2021
- HealthCare.gov | Create an Account | Last accessed July 2021