How do Medicare and Medicaid work together?

You qualified for Medicaid and you already had Medicare, and now two programs are supposed to cover one person. The question underneath is which card comes out at the desk. Medicare answers that in one sentence, and the answer is more specific than the one in general circulation.

How do Medicare and Medicaid work together?

They run as two programs with a fixed order, not as one merged benefit. Medicare pays first for Medicare covered services. Medicaid pays last, after Medicare and any other health insurance you have, and it covers some things Medicare does not.

Start with what Medicaid is, in Medicare's own description. It is a joint federal and state program that helps cover medical costs for certain low income people, families and children, pregnant women, the elderly, and people with disabilities. Medicare adds that Medicaid also helps cover medical costs for other adults.

Two words in that sentence do a lot of work. Medicare states separately that the rules around who is eligible for Medicaid are different in each state.

The two programs do not cover the same ground. Medicare states that Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services.

So this is not one benefit topped up by another. It is two benefits with different jobs and a settled order of payment.

One thing holding both does not do is decide how you take your Medicare. Medicare states that you can still pick how you get your Medicare coverage, either Original Medicare or Medicare Advantage. That choice stays yours.

Before the order matters, the status has a name and a precise definition.

What is a dual eligible?

Medicare's own definition is short. People who have both Medicare and full benefit Medicaid coverage are dually eligible. The phrase describes what you hold, not a third program you join, and it is full benefit Medicaid that the definition turns on.

Read the words full benefit carefully, because they are the hinge. Medicare's definition does not say anyone with any Medicaid help. It says full benefit Medicaid coverage.

That distinction runs through everything else on this page. What your state pays toward your Medicare costs depends on the level of Medicaid you qualify for, and Medicare says so directly.

The status also carries something with it automatically. Medicare states that if you have Medicare and qualify for full benefit Medicaid coverage, you will automatically get Extra Help with your drug costs. Extra Help is a separate Medicare program with its own rules, and this publication covers what it is and who qualifies on its Extra Help pages.

Dually eligible is Medicare's label for holding both coverages. What it changes is the order in which they pay.

Which program pays first?

Medicare pays first. Medicare states that when you are a dual eligible and you get Medicare covered services, Medicare pays first, and that Medicaid pays last, after Medicare and any other health insurance you have. Last is not the same as second.

Medicaid is not your second payer, it is your last one. That reading is this publication's rather than a phrase Medicare prints, and one of Medicare's own sentences produces it.

Medicare's sentence is that Medicaid pays last, after Medicare and any other health insurance you have. The pages that rank for this question describe Medicaid as the secondary plan, which is not the word Medicare uses.

If Medicare and Medicaid are the only two coverages you hold, second and last describe the same position and nothing turns on the word. The difference appears the moment any other health insurance exists alongside them.

In that case Medicare's wording puts Medicaid behind that other insurance too. Its sentence reads: after Medicare and any other health insurance you have. That reading is ours. The sentence is Medicare's.

Drug costs sit outside this queue rather than inside it. Medicare states that if you are dually eligible, Medicare covers your prescription drugs, and that you will automatically be enrolled in a Medicare drug plan that covers your drug costs instead of Medicaid.

That enrollment happens whether or not you act. Medicare adds that if Medicare does not cover your prescription, Medicaid may still cover it in certain situations, so the two programs meet again at the edges of the formulary.

What Medicaid pays for, once its turn arrives, is a mix of services and costs.

What does Medicaid cover that Medicare does not?

Medicare names two things directly. Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services. It also pays costs rather than services: with full benefit Medicaid your state pays your Part B premium each month.

Those are two different kinds of help and it is worth seeing them apart.

	Medicare	Medicaid
Nursing home care	Not normally covered by Medicare	Named by Medicare as a Medicaid benefit
Personal care services	Not normally covered by Medicare	Named by Medicare as a Medicaid benefit
Your monthly Part B premium	You pay it yourself	Your state pays it with full benefit Medicaid
A drug Medicare does not cover	Not covered	May still be covered in certain situations

The third row is the one that shows up in a bank account rather than at a clinic. Medicare states that if you have Medicare and qualify for full benefit Medicaid coverage, your state will pay your Medicare Part B monthly premiums.

There is more that a state may pay, and Medicare attaches a condition to it. Depending on the level of Medicaid you qualify for, your state might pay for your share of Medicare costs, like deductibles, coinsurance and copayments, and your Part A premiums if you have to pay a premium for that coverage.

Note the phrase depending on the level. Medicare does not promise every dual eligible the same help with cost sharing, and it does not publish the levels on this page.

Medicare also states that Medicaid may pay for other drugs and services that Medicare does not cover, which is the same edge the formulary rule describes from the other side.

All of that follows from qualifying, and qualifying is where this publication stops short.

How do I qualify for both?

Through your state, and the rules are not the same in every state. Medicare states that eligibility rules differ in each state, and that generally you must meet your state's rules for income and resources, plus others like being a resident of the state.

Through your state, and the rules are not the same in every state.

Medicare's instruction for finding out is to contact your State Medical Assistance office, which is the Medicaid office for your state.

This publication does not advise on qualifying for Medicaid. That is a deliberate limit rather than a gap in the research. Naming Medicaid here to explain what Medicare does and does not do is as far as this page goes, and your state's Medicaid office is where Medicare itself sends the question.

What can be said is the Medicare side of the line. The status Medicare recognises is full benefit Medicaid coverage, and that is what makes someone dually eligible in Medicare's own definition.

One recent rule is worth stating exactly, and its second half is the part that answers this reader. Medicare states that starting January 1, 2027, or earlier in some states, certain adults must complete at least 80 hours per month of work or other approved activities to qualify for Medicaid and keep their coverage. It states in the next sentence that this requirement does not apply to people with Medicare.

That second sentence is the one that answers this page's reader. A reader who already has Medicare is outside the work requirement, in Medicare's own words.

For anyone who does hold both, there is a kind of plan built specifically for the combination.

What is a D-SNP plan?

A Dual Eligible Special Needs Plan is one of three kinds of Special Needs Plan, and it is for people eligible for both programs. Medicare states that D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits.

Medicare attaches a condition to that coordination. It says the coordination depends on the state and on your eligibility, so what a D-SNP actually joins up is not the same everywhere.

The three types of Special Needs Plan are the Dual Eligible plan, the Chronic Condition plan and the Institutional plan. To join any of them you need Medicare Part A and Part B, you must live in the plan's service area, and you must meet the eligibility rules for one of the three.

Some D-SNPs go further than coordinating. Medicare states that some, called integrated D-SNPs, combine both your Medicare benefits and most or all of your Medicaid benefits and services through a single plan.

Medicare then sets out what every integrated D-SNP has to do, and this is the clearest published description of what integration actually buys you.

• One member ID card that works for both your Medicare and Medicaid coverage
• A single health risk assessment that covers both programs
• A care coordinator or case manager who helps manage your care and develops a personal care plan
• One process for both appeals and complaints, for any issue related to either coverage

Two further facts apply to every Special Needs Plan. Medicare states that all of them must provide Medicare drug coverage, and that they are either HMO or PPO plans covering the same Part A and Part B benefits that all Medicare Advantage plans cover.

There is a condition on staying. Medicare states that you can only stay enrolled in a Special Needs Plan while you continue to meet its special eligibility rules, and that if you lose the plan because you no longer meet its conditions you may be eligible for a Special Enrollment Period to join another plan.

A D-SNP is not the only option built for this reader. Medicare names Medicare-Medicaid Plans, which are available only in certain states, and Program of All-Inclusive Care for the Elderly plans, which it says can help certain people get care outside of a nursing home.

What this means for you

Dual eligibility is not a merged program. It is Medicare paying first, your state picking up costs Medicare leaves, and Medicaid paying last, after every other insurance you hold. Where you qualify and what your state pays are state questions, not federal ones.

The word to be careful with is secondary. Medicare's own sentence puts Medicaid last, after Medicare and any other health insurance you have, and that is a different position from second whenever a third coverage exists.

What you gain beyond the order is real. Your state pays your Part B premium with full benefit Medicaid, it may pay deductibles, coinsurance and copayments depending on your level, and Medicaid covers nursing home care and personal care services that Medicare does not normally cover.

Your drugs move to the Medicare side. You are enrolled automatically in a Medicare drug plan, and Medicaid may still cover a prescription Medicare does not, in certain situations.

For what Extra Help is and who gets it automatically, read this publication's pages on Extra Help income limits. For how Medicare sits alongside a job's insurance instead, read the article on Medicare and employer insurance.

FAQ

Does Medicaid pay second or last?

Last, and Medicare's own page is specific about it. It states that Medicare pays first when you are a dual eligible and you get Medicare covered services, and that Medicaid pays last, after Medicare and any other health insurance you have.

If Medicare and Medicaid are your only two coverages, last and second describe the same spot and nothing turns on the word. If you also hold any other health insurance, Medicare's wording puts Medicaid behind that too. Pages that describe Medicaid as your secondary plan are not using the word Medicare uses.

The practical effect is the same either way: Medicaid is the coverage that settles what is left once everything else has taken its turn, so it is never the payer to look to first for a service Medicare covers.

Do I have to be on full Medicaid to count as dually eligible?

Medicare's definition turns on it. It states that people who have both Medicare and full benefit Medicaid coverage are dually eligible. That phrase, full benefit, is doing real work, because Medicare separately says that what your state might pay toward your Medicare costs depends on the level of Medicaid you qualify for.

So the level is not a formality. With full benefit Medicaid coverage, Medicare states that your state will pay your Medicare Part B monthly premiums and that you will automatically get Extra Help with your drug costs. Your state Medical Assistance office is the place Medicare directs you to for the levels themselves.

Will I be automatically enrolled in a Medicare drug plan?

Yes, and Medicare frames it as protection rather than a default. It states that if you are dually eligible, Medicare covers your prescription drugs, and that you will automatically be enrolled in a Medicare drug plan that will cover your drug costs instead of Medicaid.

Medicare adds that if Medicare does not cover your prescription, Medicaid may still cover it in certain situations, so the two programs still meet at the edge of what a plan covers.

Alongside that, Medicare states that a dual eligible automatically gets Extra Help with drug costs, which is a separate program with its own rules covered elsewhere on this site.

Does the new Medicaid work requirement apply to me?

Not if you have Medicare, and Medicare says so in the sentence directly after it introduces the rule. It states that starting January 1, 2027, or earlier in some states, certain adults must complete at least 80 hours per month of work or other approved activities to qualify for Medicaid and keep their coverage.

It then states that this requirement does not apply to people with Medicare. Both sentences sit together on the same page, and the second is the one that answers this reader. Anything beyond that, including how a state will apply the rule to anyone else, is not published on the page this article draws from.

What makes an integrated D-SNP different from an ordinary one?

Medicare draws the line at whether the two coverages become one plan. It states that D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits, depending on the state and your eligibility. Some, called integrated D-SNPs, combine both your Medicare benefits and most or all of your Medicaid benefits and services through a single plan.

Medicare then lists four things every integrated version must do: give you one member ID card covering both, offer a single health risk assessment across both programs, provide a care coordinator or case manager who develops a personal care plan, and run one process for both appeals and complaints.

Can I lose a Special Needs Plan?

Yes, and the condition is the one that got you in. Medicare states that you can only stay enrolled in a Special Needs Plan if you continue to meet its special eligibility rules.

For a D-SNP those rules are being eligible for both Medicare and Medicaid, so a change in your Medicaid status is what would put the plan at risk rather than anything about your health. Medicare does not leave that as a dead end.

It states that if you are losing your plan because you no longer meet the plan's conditions, you may be eligible for a Special Enrollment Period to join another plan. Availability also varies by state and county.