How does Medicaid work with Medicare to cover my health care costs?

Section IX.c. Medicaid and Medicare
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All states offer a variety of Medicaid programs and several can help people with Medicare. If you qualify for a Medicaid program (no matter which one), Medicaid can help pay for costs and services that Medicare does not cover. Medicare is the primary payer and Medicaid pays second.

  • For services that both Medicare and Medicaid can cover (such as doctors’ visits, hospital care, home care and skilled nursing facility care), Medicare will pay first and Medicaid will pay second, by covering your remaining costs, such as the Medicare coinsurances and copayments.

    • In many cases if you have Medicaid, you will automatically be enrolled in a Medicare Savings Program (the Qualified Medicare Beneficiary program or QMB). Also run through Medicaid, QMB will offer additional assistance by paying your Medicare Part B premium, deductibles, coinsurances and copayments. You will need to meet the guidelines for QMB eligibility in your state.
    • If you have Medicare, Medicaid and QMB, you should be able to go to any doctor or provider who takes Medicare, Medicaid or is in your Medicare private health plan’s network without having to pay the Medicare coinsurances or deductibles. You may still have to pay the Medicaid copayment for the service, depending on the rules in your state. However, if you go to see a provider who takes Medicare and Medicaid, the provider is most likely to bill correctly. If your provider bills you incorrectly, you should call your local State Health Insurance Assistance Program (SHIP)

      Note: If you have Medicaid and are still paying your Part B premium, you should contact your local Medicaid office to see about enrolling in QMB.

  • Medicaid can cover much more long-term care than Medicare does. Medicare requirements for coverage of long-term care services, such as home care and skilled nursing facility (nursing home) services, are generally stricter than Medicaid’s and the coverage itself is much more limited.

    • If you qualify for Medicare-covered skilled nursing facility care or home care, Medicaid will pay second to cover your Medicare coinsurances, copayments and deductibles. If your Medicare skilled nursing facility coverage ends (Medicare covers a limited number of days) or if your home health care is not comprehensive enough (Medicare generally covers a limited amount per week), Medicaid can cover additional services. If you do not qualify for Medicare coverage of long-term services at all, Medicaid may cover it for you.  
  • Medicaid will also pay for medical services not covered at all by Medicare as long as they are covered by Medicaid. Such services may include routine dental services and transportation to and from doctors’ appointments.
  • Medicaid can help cover your prescription drug costs. If you have Medicare and qualify for a Medicaid program, you then automatically qualify for Extra Help, the federal program that helps with the cost of Medicare prescription drug coverage (Part D). Note: If you will lose your retiree or union coverage by enrolling in a Medicare private drug plan, you may not have to take Medicare drug coverage. Contact your Medicaid office to find out.

    Depending on your state, Medicaid may wrap around your Medicare drug plan to cover drugs or pick up costs that Medicare does not. 

  • Some states may require people with Medicare and Medicaid to enroll in a Medicaid private health plan. Your state may encourage you to enroll in a Medicare private health plan that your Medicaid private health plan is designed to work with. But even if you are required to enroll in a Medicaid private health plan in your state, you cannot be required to enroll in a Medicare private health plan. Check with your local Medicaid office to learn more about your health plan options. To find out the exact Medicaid programs you may be eligible for, you should contact your local Medicaid office and speak to a counselor. Financial eligibility guidelines and covered services vary greatly from state to state and from program to program. Be aware that you may be able to have higher income than general eligibility guidelines suggest because certain income may not be counted, or you may be able to qualify another way—for example, by spending down your income on medical expenses.

 

     


Case Examples
Medicaid mistakenly failed to pay Ms. B's Medicare Part B premiums.

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Could I be eligible for a government program other than Medicaid to help with my health care costs (Medicare Savings Programs)?

Types of home health care that Medicare will pay for

Medicare coverage of skilled nursing facility (SNF) care

Getting Medicaid if you do not need long-term care and have Medicare

If I have Medicare and full Medicaid how will my drug coverage work?

 
LINKS
Medicaid-covered Benefits By State

State Health Insurance Assistance Program (SHIP) Directory

State Medicaid Programs

 
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