Can I Have Both Medicare and Medicaid? Understanding Dual Eligibility

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Getting Help from Two Health Programs

Medicare is primarily federal health insurance for older adults and certain individuals with disabilities, while Medicaid is a joint federal and state program offering coverage to eligible low-income individuals and families.

A key point often missed is that some individuals with limited financial means may qualify to receive benefits from both Medicare and Medicaid simultaneously. These individuals are commonly referred to as being “dually eligible” or “Medicare-Medicaid enrollees.”

Being dually eligible can provide significant advantages, as the two programs work together to cover a broader range of services and substantially reduce out-of-pocket healthcare costs. This article explains what Medicare and Medicaid are, who might qualify for both, how the programs coordinate benefits, available health plan options, and how to apply for this assistance.

What is Medicare? Your Federal Health Insurance

Medicare’s Purpose and Who It Serves

Medicare is the United States’ federal health insurance program. Its primary purpose is to provide health coverage for people aged 65 or older. However, eligibility extends beyond age. Certain younger individuals with disabilities can also qualify for Medicare, typically after receiving Social Security Disability Insurance (SSDI) benefits for 24 months.

Additionally, people of any age diagnosed with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a transplant) or Amyotrophic Lateral Sclerosis (ALS, often called Lou Gehrig’s disease) are eligible for Medicare.

The program is managed federally by the Centers for Medicare & Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services.

Importantly, initial eligibility for Medicare is generally triggered by reaching age 65, receiving disability benefits for the required period, or having a qualifying diagnosis like ESRD or ALS. Unlike Medicaid, a person’s income level does not typically determine whether they are eligible for Medicare in the first place, although income can affect the premiums paid for certain parts of the program later on.

This event-driven nature means individuals approaching age 65 or those diagnosed with qualifying conditions should explore Medicare enrollment options regardless of their current financial situation.

The Different Parts of Medicare Explained

Medicare is structured into different “parts,” each covering distinct types of services. Understanding these parts is crucial for navigating coverage options:

Medicare Part A (Hospital Insurance): This part helps cover costs associated with inpatient care. This includes stays in a hospital, limited-time care in a skilled nursing facility (SNF) following a qualifying hospital stay, hospice care for individuals with terminal illnesses, and certain types of home health care.

A significant advantage is that most individuals receive Part A premium-free. This typically applies if the individual or their spouse paid Medicare taxes for a sufficient period while working, generally equivalent to 10 years or 40 quarters of work. Those who do not meet the work history requirements for premium-free Part A may have the option to purchase it by paying a monthly premium.

Medicare Part B (Medical Insurance): Part B covers a wide range of medically necessary outpatient services. This includes services from doctors and other healthcare providers, outpatient hospital care, durable medical equipment (DME) such as wheelchairs, walkers, and hospital beds, some home health services, and numerous preventive services like screenings, vaccinations, and annual “Wellness” visits.

Unlike Part A, most beneficiaries must pay a monthly premium for Part B. This premium amount can be higher for individuals with greater incomes. It’s important to enroll in Part B when first eligible, as delaying enrollment without having other qualifying coverage (like from an active employer) can result in a life-long late enrollment penalty.

Medicare Part C (Medicare Advantage): These plans are offered by private insurance companies that have been approved by Medicare. They serve as an alternative way for beneficiaries to receive their Medicare Part A and Part B benefits.

Medicare Advantage plans often bundle Part A, Part B, and Part D (prescription drug coverage) into a single plan. They may also offer additional benefits not covered by Original Medicare (Parts A and B alone), such as routine vision, dental, and hearing care.

However, these plans typically have provider networks, meaning beneficiaries may need to use doctors and hospitals within the plan’s network for care to be covered at the lowest cost, and out-of-pocket costs can differ from Original Medicare.

Medicare Part D (Prescription Drug Coverage): Part D helps cover the cost of outpatient prescription drugs, including many recommended shots or vaccines.

This coverage is provided through private insurance plans approved by Medicare. Beneficiaries can obtain Part D coverage either through a standalone Prescription Drug Plan (PDP) that works alongside Original Medicare, or as part of a Medicare Advantage plan that includes drug coverage (MA-PD).

Individuals with limited income and resources may qualify for the Extra Help program (also known as the Low-Income Subsidy or LIS) to lower their Part D costs.

Medigap (Medicare Supplement Insurance): These are insurance policies sold by private companies designed to fill the “gaps” in Original Medicare coverage.

Medigap plans help pay for some or all of the beneficiary’s share of costs under Original Medicare, such as deductibles, coinsurance, and copayments. It is important to note that Medigap policies only work with Original Medicare (Parts A and B); they cannot be used with Medicare Advantage (Part C) plans.

The existence of deductibles, coinsurance (like the typical 20% cost-sharing for Part B services), and coverage limitations within Original Medicare creates potential financial exposure for beneficiaries.

Notably, Original Medicare does not cover certain essential services like long-term nursing home care, most dental care, routine eye exams for glasses, or hearing aids. These coverage gaps and cost-sharing requirements underscore the need for additional coverage for many beneficiaries.

Those who can afford it might purchase private Medigap policies. For individuals with limited income and resources, Medicaid often becomes the necessary solution, covering both the Medicare cost-sharing and providing benefits for services Medicare doesn’t cover, making dual eligibility particularly valuable.

What Services Does Medicare Typically Cover?

Original Medicare (Parts A and B) covers a broad array of hospital and medical services, provided they are considered “medically necessary” to diagnose or treat a condition and meet accepted standards of medical practice.

Coverage decisions are based on federal and state laws, national coverage determinations made by CMS, and local coverage decisions made by companies that process Medicare claims in each state.

Key covered services generally include:

• Inpatient hospital care
• Skilled nursing facility care (limited duration after a hospital stay)
• Hospice care
• Some home health services
• Doctor visits and services from other health care providers
• Outpatient care and procedures
• Durable Medical Equipment (DME) like wheelchairs, walkers, oxygen
• Preventive services such as flu shots, mammograms, colonoscopies, and diabetes screenings
• Mental health services (inpatient and outpatient)
• Ambulance services
• Clinical laboratory tests

A comprehensive list of covered items and services is extensive. To determine if a specific test, item, or service is covered, beneficiaries can talk to their doctor or use the official search tool on the Medicare website.

What is Medicaid? State and Federal Health Coverage

Medicaid’s Purpose and Who It Serves

Medicaid is a public health insurance program established to provide free or low-cost health coverage to eligible individuals and families with limited income and resources.

Unlike Medicare, which is primarily federal, Medicaid is a partnership between the federal government and state governments. The federal government sets core requirements and provides partial funding, while each state administers its own Medicaid program.

This joint structure means that while Medicaid serves similar core populations across the country, specific eligibility rules and covered benefits can vary from state to state.

Generally, Medicaid provides coverage for diverse groups, including eligible low-income children, pregnant women, parents and caretaker relatives of dependent children, adults (particularly in states that have adopted Medicaid expansion under the Affordable Care Act), individuals with disabilities, and people aged 65 and older.

Millions of seniors and people with disabilities are enrolled in both Medicare and Medicaid.

How Medicaid Eligibility Works (Income, Assets, and Other Factors)

Determining eligibility for Medicaid is often more complex than for Medicare because it involves multiple factors that can differ significantly based on the state and the specific eligibility group an individual falls into. The primary factors include:

Income: Income limits are a central component of Medicaid eligibility and are typically based on the Federal Poverty Level (FPL). However, the specific FPL percentage used as the limit varies widely depending on the state and the applicant’s category (e.g., pregnant woman, child, parent, non-disabled adult, senior, person with a disability).

There are two main methodologies used to calculate income:

• Modified Adjusted Gross Income (MAGI): Introduced by the Affordable Care Act (ACA), MAGI rules are used to determine financial eligibility for most children, pregnant women, parents/caretakers, and adults covered under Medicaid expansion. MAGI considers taxable income and tax filing relationships, aiming for a standardized approach aligned with Marketplace coverage. Generally, MAGI-based pathways do not include an asset or resource test.
• Non-MAGI Rules: These rules apply to individuals whose eligibility is based on being age 65 or older, blind, or having a disability. Eligibility for these groups is often determined using income methodologies similar to the Supplemental Security Income (SSI) program. Crucially, these non-MAGI pathways typically do include limits on assets or resources.

Assets/Resources: For individuals applying under non-MAGI rules (typically seniors and people with disabilities), countable assets must fall below a certain limit. Assets considered often include money in bank accounts, stocks, bonds, and sometimes vehicles or property other than a primary residence.

In many states, the asset limit for an individual is $2,000, and for a couple, it’s often $3,000, though these figures can vary. Some states, like California (effective January 1, 2024), have eliminated asset tests for these groups.

For applicants seeking Medicaid coverage for long-term care, states employ a “Look-Back Period” (typically 60 months) to review asset transfers made for less than fair market value, which can result in a penalty period of Medicaid ineligibility.

Non-Financial Criteria: Applicants must meet certain non-financial requirements. These generally include being a resident of the state where they are applying and being a U.S. citizen or a lawfully present non-citizen meeting specific qualifications.

Specific eligibility categories are also defined by factors like age, pregnancy status, disability status, or family role (e.g., parent/caretaker).

The complexity arising from state variations and differing rules (MAGI vs. non-MAGI, income levels, asset tests) makes it essential for individuals to check the specific requirements in their state. Generalizations can be misleading, and eligibility in one state does not guarantee eligibility in another.

Often, the most reliable way to determine eligibility is to submit an application.

What Services Does Medicaid Typically Cover?

Medicaid provides a comprehensive set of health benefits, although the exact package varies by state. Federal law mandates that all state Medicaid programs cover certain essential services. These mandatory benefits include:

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Laboratory and X-ray services
• Home health services
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for individuals under 21

Beyond these requirements, states have the flexibility to cover a wide range of optional benefits. Many states choose to cover services that are particularly important for dual eligibles and individuals with chronic conditions or disabilities. Common optional benefits include:

• Prescription drugs
• Physical and occupational therapy
• Speech, hearing, and language disorder services
• Dental services (coverage scope varies greatly by state)
• Vision services, including eyeglasses
• Hearing aids
• Long-Term Services and Supports (LTSS), such as nursing facility care beyond Medicare’s limits, and various home and community-based services (HCBS) designed to help people remain in their homes
• Case management
• Non-emergency medical transportation

Because states choose which optional benefits to offer, the exact list of covered services can differ significantly. Some states may require beneficiaries (typically adults) to pay small amounts for certain services, known as copayments or cost-sharing.

Can You Have Both? Understanding Dual Eligibility

What “Dual Eligible” Means

The term “dual eligible” or “Medicare-Medicaid enrollee” specifically refers to an individual who is enrolled in Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) and is also eligible for and receiving some form of Medicaid benefit.

This includes individuals who qualify for full Medicaid coverage as well as those who qualify for one of the Medicare Savings Programs (MSPs), which help pay for Medicare costs.

Millions of Americans—over 12 million in recent years—are dually eligible for both programs. This population often includes individuals with complex health needs, multiple chronic conditions, disabilities, and requirements for long-term services and supports.

Pathways to Dual Eligibility: Meeting Both Sets of Rules

Becoming dually eligible requires satisfying the distinct eligibility criteria for both programs. First, an individual must qualify for Medicare, typically based on age (65+), having a qualifying disability (usually after 24 months of SSDI), or having ESRD or ALS.

Second, the individual must also meet the requirements for a Medicaid program in their state. This could be full-benefit Medicaid or one of the Medicare Savings Programs (MSPs).

Crucially, qualifying for Medicaid or an MSP involves meeting specific financial criteria, including income limits and, for many pathways relevant to seniors and people with disabilities (non-MAGI pathways), asset limits. These financial thresholds vary by state and program.

Help with Medicare Costs: Medicare Savings Programs (MSPs)

For Medicare beneficiaries who have limited income and resources but may not qualify for full Medicaid, the Medicare Savings Programs (MSPs) offer vital assistance. These are specific Medicaid-administered programs designed solely to help cover the costs associated with Medicare. Enrollment in an MSP makes an individual dually eligible.

The main MSPs are structured to provide increasing levels of assistance based generally on income, forming a kind of support ladder. However, the asset limits applied in many states can pose a barrier even for those with low incomes but modest savings. Several states have recognized this and eliminated asset tests for MSPs. It’s crucial to check state-specific rules.

Here are the primary MSPs:

Qualified Medicare Beneficiary (QMB): This program provides the most comprehensive help with Medicare costs. It pays for Medicare Part A premiums (if applicable), Medicare Part B premiums, and, significantly, all Medicare deductibles, coinsurance, and copayments.

Federal law prohibits Medicare providers from billing individuals enrolled in the QMB program for any Medicare Part A or Part B cost-sharing. This protection against potentially substantial out-of-pocket costs makes QMB status particularly valuable.

Generally, the income limit is at or below 100% of the FPL, and asset limits apply in many states.

Specified Low-Income Medicare Beneficiary (SLMB): The SLMB program helps by paying the monthly Medicare Part B premium only. Individuals qualifying for SLMB generally have incomes between 100% and 120% of the FPL. The asset limits are typically the same as for QMB.

An individual might qualify for SLMB only (partial benefit) or SLMB plus full Medicaid benefits (SLMB Plus) if they meet criteria for another Medicaid category. SLMB recipients automatically qualify for Extra Help with Medicare Part D costs.

Qualifying Individual (QI): The QI program also helps pay the Medicare Part B premium only. Eligibility is generally for individuals with incomes between 120% and 135% of the FPL. Asset limits are typically the same as QMB/SLMB.

A key distinction is that individuals cannot be otherwise eligible for full Medicaid benefits to qualify for QI. Funding for the QI program is subject to annual federal appropriations and may be limited. QI recipients also automatically qualify for Extra Help.

Qualified Disabled and Working Individual (QDWI): This program is specifically for certain individuals under age 65 with disabilities who lost their premium-free Medicare Part A coverage because they returned to work. The QDWI program helps by paying their Medicare Part A premium only.

Income limits are higher (up to 200% FPL), but asset limits are lower than for other MSPs.

The following table summarizes the federal guidelines for these programs. Remember that states may use higher income or resource limits, and some states do not have an asset limit for MSPs. Always check with the specific state Medicaid agency.

Medicare Savings Programs (MSPs) at a Glance (Federal Guidelines for 2025 – Check Your State!)

*Income limits shown are based on 2025 FPL guidelines for most states and DC (slightly higher in AK & HI) and generally include a small income disregard. Check state-specific limits.

**Asset limits shown are federal guidelines for 2025. Some states use higher limits or have eliminated the asset test entirely for MSPs.

Full vs. Partial Dual Eligibility

It is crucial to understand that not all dually eligible individuals receive the same level of benefits. There are two main categories:

Full-Benefit Dual Eligibles: These individuals are enrolled in Medicare Part A and/or B and also receive the complete package of Medicaid benefits available in their state.

This group includes those who qualify for an MSP and separately meet the criteria for a full Medicaid category (often designated as QMB Plus or SLMB Plus), as well as those who qualify for full Medicaid based on other criteria (like low income and disability) and happen to also have Medicare.

Full-benefit dual eligibles receive assistance with their Medicare costs (premiums and cost-sharing, depending on their MSP status) plus coverage for the additional services included in their state’s Medicaid plan, such as long-term care, dental, and vision care.

Partial-Benefit Dual Eligibles: This group consists of individuals enrolled in Medicare who qualify for only one of the Medicare Savings Programs (QMB Only, SLMB Only, QI, or QDWI) but do not qualify for full Medicaid benefits.

Their Medicaid assistance is limited to help with specific Medicare costs—premiums and, for QMBs, cost-sharing. They do not receive the broader range of services covered by full Medicaid unless they qualify through a separate pathway.

This distinction is vital because simply knowing someone is “dual eligible” does not fully describe their coverage. The scope of benefits available beyond Medicare, particularly access to services like long-term care, dental, and vision, depends heavily on whether the individual has full or partial Medicaid benefit status.

How Medicare and Medicaid Work Together for Dual Eligibles

Who Pays First? The Coordination Rule

When an individual is dually eligible and receives a healthcare service covered by both Medicare and Medicaid, a clear rule dictates the order of payment: Medicare always pays first.

Medicare processes the claim as the primary payer and pays its share according to its rules.

After Medicare has paid its portion, the claim is then sent to Medicaid. Medicaid acts as the secondary payer and may cover some or all of the remaining costs for the service, but generally only up to the amount that Medicaid would have paid for that service if it were the primary payer.

This coordination ensures that providers are paid correctly and helps prevent cost-shifting between the two programs, a key goal of effective Medicare-Medicaid coordination.

Medicaid’s Help with Your Medicare Out-of-Pocket Costs

A primary benefit of dual eligibility, especially through the Medicare Savings Programs (MSPs), is help with Medicare’s own out-of-pocket costs. Medicaid assists with:

Medicare Premiums:

• Part B Premium: Medicaid pays the monthly Part B premium for individuals enrolled in the QMB, SLMB, and QI programs. This provides significant monthly savings for beneficiaries.
• Part A Premium: For the small percentage of Medicare beneficiaries who owe a premium for Part A (because they lack sufficient work history), Medicaid pays this premium if they are enrolled in the QMB or QDWI programs.

Medicare Deductibles, Coinsurance, and Copayments (Cost-Sharing):

• For QMBs: Individuals enrolled in the QMB program (both QMB Only and QMB Plus) receive the highest level of protection. Medicaid covers their Medicare Part A and Part B deductibles, coinsurance, and copayments. Critically, federal law prohibits healthcare providers from billing QMB individuals for these Medicare cost-sharing amounts. This “QMB protection” shields them from potentially large bills associated with Medicare-covered services.
• For Other Full-Benefit Dual Eligibles: Individuals who have full Medicaid coverage but are not in the QMB program (e.g., SLMB Plus, or those qualifying for full Medicaid independently) may still receive help with cost-sharing. For services covered by both Medicare and Medicaid, their liability is often limited to any applicable nominal Medicaid copayment. However, for services covered only by Medicare, these individuals might still be responsible for the standard Medicare deductible and coinsurance, unless their state Medicaid program specifically chooses to cover these costs for them.

Services Medicaid Covers That Medicare Usually Doesn’t

Beyond helping with Medicare’s costs, full-benefit dual eligibility grants access to services covered under the state’s Medicaid plan, many of which Original Medicare does not cover or covers only in very limited circumstances. This is where the value of full dual eligibility becomes most apparent, particularly for individuals with chronic health issues or disabilities. Key examples include:

Long-Term Services and Supports (LTSS): This is perhaps the most significant area of difference. While Medicare covers short-term skilled nursing facility care after a hospital stay, it does not pay for long-term custodial care in a nursing home.

Medicaid, however, is the primary payer for LTSS in the U.S. For eligible individuals, Medicaid can cover extended nursing home stays and a wide range of Home and Community-Based Services (HCBS) aimed at helping people live independently outside of institutions.

HCBS can include personal care assistance (help with bathing, dressing, eating), adult day care, home modifications (like ramps), respite care for family caregivers, meal delivery, and personal emergency response systems.

Access to these LTSS benefits is often the primary reason individuals with significant care needs seek full Medicaid eligibility.

Dental Care: Original Medicare generally does not cover routine dental care like checkups, cleanings, fillings, or dentures. Full-benefit Medicaid often covers some level of dental services, although the scope of coverage varies dramatically from state to state.

Vision Care: Similarly, Original Medicare doesn’t cover routine eye exams for eyeglasses or the eyeglasses themselves. Full-benefit Medicaid frequently covers these vision services, again with state-specific variations.

Hearing Aids: Hearing aids are another item generally not covered by Original Medicare but potentially covered under a state’s full-benefit Medicaid plan.

Non-Emergency Medical Transportation (NEMT): Medicaid can cover transportation to and from medical appointments and pharmacies for eligible individuals who lack other means of transportation.

Access to these additional services highlights the comprehensive nature of coverage for those with full dual eligibility, addressing health needs beyond the scope of Medicare alone.

Health Plan Options for Dual Eligibles: D-SNPs

What Are Dual Eligible Special Needs Plans (D-SNPs)?

For individuals who are dually eligible, there are specific health plan options designed to better coordinate their care. One prominent option is the Dual Eligible Special Needs Plan, or D-SNP.

D-SNPs are a type of Medicare Advantage (Medicare Part C) plan offered by private insurance companies that have contracts with Medicare.

These plans are specifically tailored for and restricted to individuals who are entitled to benefits under both Medicare (Title XVIII of the Social Security Act) and medical assistance from a state plan under Medicaid (Title XIX). They aim to provide a more integrated approach to managing the healthcare needs of this population.

How D-SNPs Coordinate Your Medicare and Medicaid Benefits

The primary purpose of D-SNPs is to improve the coordination and integration of Medicare and Medicaid benefits, offering a potentially simpler and more effective healthcare experience for dual eligibles. They work towards this goal in several ways:

• Integrated Coverage: Like other Medicare Advantage plans, D-SNPs provide all Medicare Part A and Part B benefits and typically include Part D prescription drug coverage, bundling these benefits into one plan.
• Care Coordination: A hallmark of D-SNPs is their focus on care coordination. Many plans offer specialized programs to help members navigate the complexities of both Medicare and Medicaid. This can involve assistance accessing primary care, specialists, behavioral health services, long-term services and supports (LTSS), and necessary social services. D-SNPs are required to have a documented “Model of Care” (MOC) that outlines their specific strategies for providing coordinated care to their members.
• Cost-Sharing Assistance: D-SNPs work with state Medicaid programs to cover Medicare cost-sharing. Some D-SNPs are designed to offer Medicare services with zero-dollar cost-sharing for the member.
• Provider Networks: D-SNPs operate with provider networks, which may include doctors, hospitals, and specialists experienced in serving the needs of dually eligible individuals.
• Simplified Experience: By integrating benefits and coordinating care through a single plan, D-SNPs aim to reduce the fragmentation and administrative burden that can arise when navigating Original Medicare and separate Medicaid systems.

D-SNPs represent a significant shift towards managed, integrated care models for the dual-eligible population. While they offer the potential benefits of better coordination and potentially lower costs, beneficiaries should also consider the limitations inherent in managed care, such as the need to use network providers. Enrollment in integrated care options like D-SNPs has been increasing over time.

How to Apply for Medicare and Medicaid

Applying for Medicare

Applications for Medicare (specifically Original Medicare, Parts A and B) are primarily handled by the Social Security Administration (SSA). Individuals who are already receiving Social Security retirement or disability benefits are typically enrolled automatically in Medicare Parts A and B when they become eligible (e.g., at age 65 or after 24 months of disability benefits) and do not need to file a separate application.

For those who need to actively apply, there are several ways to do so:

• Online: The SSA encourages online applications as the most convenient method. Individuals can apply for Medicare only, or for both Medicare and Social Security retirement benefits, through the SSA website. The relevant pages are typically found at https://www.ssa.gov/benefits/medicare/ or https://www.ssa.gov/medicare/sign-up. Applying online usually requires creating or signing into a personal my Social Security account for identity verification, although options exist if an account cannot be created. Applicants will need basic information such as their date and place of birth, Social Security number, information about current or past group health plan coverage, and potentially work history details.
• Phone: Individuals can apply by calling the SSA’s national toll-free number at 1-800-772-1213 (TTY 1-800-325-0778).
• In Person: Applications can also be made by visiting a local Social Security office. It is generally recommended to call ahead and make an appointment.

It is crucial to apply during the correct enrollment period to avoid coverage gaps and potential penalties. The Initial Enrollment Period (IEP) for those aging into Medicare is a 7-month period that begins 3 months before the month an individual turns 65, includes their birth month, and ends 3 months after their birth month.

Individuals who delay Part B enrollment because they have qualifying group health coverage through current employment (their own or a spouse’s) may be eligible for a Special Enrollment Period (SEP) to sign up later without penalty.

There is also a General Enrollment Period (GEP) from January 1 to March 31 each year for those who missed their IEP or SEP, but enrolling during the GEP may result in coverage delays and late enrollment penalties.

Applying for Medicaid

Unlike the centralized Medicare application process through SSA, applications for Medicaid (including the Medicare Savings Programs) must be submitted at the state level. States offer various ways to apply, and the specific methods can vary. Common application pathways include:

Through the Health Insurance Marketplace: Individuals can complete a single application online at HealthCare.gov or through their state’s Marketplace website if it uses its own platform.

This application assesses eligibility for both Marketplace plans with subsidies and Medicaid/CHIP. If the Marketplace determines that an applicant or household member is likely eligible for Medicaid or CHIP based on the information provided (primarily income for MAGI groups), it securely transmits the application information to the state Medicaid agency.

The state agency then makes the final eligibility determination and contacts the applicant about enrollment. This “no wrong door” approach simplifies the process for many, especially those applying based on MAGI income rules, as one application serves multiple programs.

Directly with the State Medicaid Agency: Applicants can also apply directly to their state’s Medicaid agency. This may be a more direct route for individuals applying based on age (65+) or disability (non-MAGI rules), as these applications often require additional information about assets not typically collected through the Marketplace application. Common methods for applying directly include:

• Online: Through the state Medicaid agency’s dedicated web portal (e.g., Mississippi uses Access.ms.gov; North Carolina uses ePASS).
• By Phone: Calling the state Medicaid agency’s helpline.
• By Mail: Downloading, printing, and mailing a paper application to the state or local Medicaid office.
• In Person: Visiting a local county social services or human services office.

Regardless of the application method, individuals will typically need to provide documentation or information to verify identity, state residency, citizenship or immigration status, Social Security numbers for applicants, household income (e.g., pay stubs, tax information), and potentially information about assets/resources if applying under non-MAGI rules. Specific requirements vary by state.

Unlike Medicare’s fixed enrollment periods, individuals can apply for Medicaid at any time during the year.

Medicaid Varies by State: What You Need to Know

Why Rules and Benefits Differ Across States

A fundamental aspect of the Medicaid program is the significant variation that exists from one state to another. While the federal government establishes baseline requirements and guidelines, states possess considerable flexibility in how they design and operate their Medicaid programs. This state-level control leads to differences in several key areas:

• Eligibility Levels: States set their own income eligibility thresholds for various population groups, often expressed as a percentage of the Federal Poverty Level (FPL). These levels can vary substantially for children, pregnant women, parents, seniors, and people with disabilities. Furthermore, states had the option under the ACA to expand Medicaid eligibility to nearly all non-elderly adults with incomes up to 138% of the FPL; not all states have adopted this expansion, creating major differences in adult eligibility. Asset rules for non-MAGI groups (seniors, disabled) can also differ, with some states adhering to federal minimums and others adopting more generous limits or eliminating asset tests altogether.
• Covered Benefits: While all states must cover federally mandated benefits, the scope of optional benefits offered varies widely. This means access to services like comprehensive dental care, vision services, hearing aids, specific therapies, and the types and extent of Home and Community-Based Services (HCBS) waivers can depend heavily on the state of residence.
• Delivery Systems: States choose how Medicaid services are delivered. Some operate primarily on a fee-for-service basis, where the state pays providers directly for each service rendered. Many states, however, contract with private Managed Care Organizations (MCOs) to provide Medicaid benefits to enrollees. The delivery system can affect provider networks and how beneficiaries access care.

Because of this state-level flexibility, it is impossible to assume that the rules or benefits available in one state will apply in another. Individuals must investigate the specific details of the Medicaid program in their own state.

Finding Your State’s Specific Medicaid Information

Given the state-specific nature of Medicaid, accessing accurate information for one’s own state is essential. Here are reliable ways to find state-specific Medicaid details:

• State Medicaid Agency Website: This is the most authoritative source for a particular state’s program rules, covered benefits, provider directories, and application procedures. The official federal Medicaid website, Medicaid.gov, provides a directory with contact information and website links for each state Medicaid agency: https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip.
• HealthCare.gov: The federal Health Insurance Marketplace website includes tools to help users find state-specific information. By selecting their state on pages like https://www.healthcare.gov/medicaid-chip/ or https://www.healthcare.gov/marketplace-in-your-state/, users can be directed to either their state’s Marketplace (if applicable) or the state Medicaid agency website and contact information.
• USA.gov: The official web portal of the U.S. government also provides links to state Medicaid agencies via its page on Medicaid and CHIP: https://www.usa.gov/medicaid-chip-insurance.
• CMS Resources: While often more technical, the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/) contains state-specific data profiles and reports related to Medicaid and dual eligibility.

Using these official resources ensures individuals get information tailored to the specific eligibility requirements and benefits offered in their state of residence.

Getting Help and Information: Resources You Can Trust

Navigating Medicare and Medicaid, especially dual eligibility, can be challenging. Fortunately, several reliable resources offer free assistance and information.

State Health Insurance Assistance Programs (SHIPs)

The State Health Insurance Assistance Program (SHIP) is a national program funded by the federal government (administered by the Administration for Community Living) that provides free, unbiased, one-on-one counseling and assistance to Medicare beneficiaries, their families, and caregivers.

SHIP counselors are highly trained volunteers and staff located in every state, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands.

SHIPs help individuals:

• Understand their Medicare benefits and choices (Parts A, B, C, D, Medigap).
• Navigate the interactions between Medicare and other insurance, including Medicaid.
• Screen for eligibility and apply for programs that help lower Medicare costs, such as the Medicare Savings Programs (MSPs) and Extra Help.
• Compare Medicare Advantage and Part D plans.
• Understand Medicare claims and appeals.
• Identify and report potential Medicare fraud and abuse (often in coordination with Senior Medicare Patrol programs).

Crucially, SHIPs are not affiliated with any insurance company and do not sell insurance products. Their counseling is objective and tailored to the individual’s needs. To find the local SHIP office, individuals can visit the national SHIP website locator at https://www.shiphelp.org/ or call the national toll-free number: 877-839-2675.

Centers for Medicare & Medicaid Services (CMS)

CMS is the federal agency responsible for administering the Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and the federal Health Insurance Marketplace. As such, its websites are primary sources of official information:

• Medicare.gov: The official U.S. government website for Medicare. It provides comprehensive information about Medicare coverage, costs, enrollment, finding health and drug plans, and finding providers. The site also hosts the annual “Medicare & You” handbook.
• Medicaid.gov: The official U.S. government website for Medicaid and CHIP. It offers information on program basics, federal policy, eligibility, benefits, and links to state Medicaid agency contacts.
• HealthCare.gov: The official site for the Health Insurance Marketplace, used for applying for Marketplace coverage, Medicaid, and CHIP.
• CMS.gov: The main agency website. While much of its content is geared towards policymakers, researchers, and providers, it contains detailed information on regulations, data, specific programs like the QMB program, and resources related to Medicare-Medicaid coordination.
• 1-800-MEDICARE (1-800-633-4227): The official Medicare helpline, available 24/7 for questions about Medicare benefits and enrollment.

CMS also produces various outreach materials, fact sheets, and infographics designed for beneficiaries to explain program details and rights.

Other Helpful Contacts

Depending on the specific need, other local organizations may provide assistance:

• Local Departments of Social Services (DSS) or Human Services: These county or city agencies often handle Medicaid and MSP applications and renewals.
• Area Agencies on Aging (AAAs): These local agencies provide services and support for older adults and often partner with SHIP to offer Medicare counseling.
• Disability Advocacy Groups: Organizations focused on specific disabilities may offer resources or assistance related to navigating health coverage options.

Utilizing these trusted resources can empower individuals to understand their eligibility for both Medicare and Medicaid, navigate the application processes, and make informed decisions about their healthcare coverage.

Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.