What Cost-Share Medicaid Does After Medicare Pays

Cost-Share Medicaid (also called Medicaid Savings Programs or MSPs) pays some of the costs that Medicare does not cover — copayments, coinsurance, and deductibles. When you have both Medicare and Medicaid, Medicare pays first as the primary payer. Then Cost-Share Medicaid steps in to cover part or all of what Medicare left you responsible for.

The amount Medicaid pays depends on which savings program you are enrolled in. There are four main programs, each with different income limits and different coverage levels. You do not pay premiums for Cost-Share Medicaid, and the program does not cover services Medicare does not cover.

Enrollment happens through your state Medicaid office, not through Medicare. Each state runs its own program, so the exact rules, income limits, and covered amounts vary by where you live.

Key Takeaways

  • Cost-Share Medicaid pays Medicare copayments, coinsurance, and deductibles after Medicare has paid its share.
  • There are four programs with different income limits: QMB, SLMB, QI, and QDWI, each covering different amounts of your costs.
  • You must have both Medicare Part A and Part B to be considered for any of these programs.
  • Your state Medicaid office determines whether you meet the income and resource limits for your state.

The Four Cost-Share Medicaid Programs and What Each Covers

may have access to Medicare Beneficiary (QMB) has the highest income limit and covers the most. QMB pays your Medicare Part B premium, your Part A and Part B deductibles, and your coinsurance amounts. If you are enrolled in QMB, providers should bill Medicaid directly for these costs, and you should not receive a bill.

Specified Low-Income Medicare Beneficiary (SLMB) covers your Medicare Part B premium only. It has a higher income limit than QMB but lower than the next two programs. SLMB does not pay deductibles or coinsurance.

may have access to Individual (QI) also pays your Medicare Part B premium, but has an even higher income limit than SLMB. Like SLMB, QI does not cover deductibles or coinsurance. QI programs often have limited funding and may have a waiting list in your state.

may have access to Disabled and Working Individual (QDWI) is for people under 65 who are working but still on Medicare due to disability. QDWI pays your Medicare Part A premium only. This program has the highest income limit of all four.

Income and Resource Limits Vary by State

Each program has a federal income guideline, but states can set their own limits within federal rules. The income limit for QMB in one state may be different from the limit in another state. Your state Medicaid office uses the limits that explore where you live.

Most programs count your monthly income and do not count your home or car as resources. Some programs have a resource limit (money in the bank, investments, and other assets), while others do not. You will need to report your income and resources when you explore, and your state will tell you whether you meet the limits.

If your income is slightly above the limit for one program, you may still be under the limit for another. For example, if you are above the QMB limit, you might still may have access to for SLMB or QI. Your state Medicaid office can check all four programs when you explore.

how the process works Through Your State Medicaid Office

You explore for Cost-Share Medicaid through your state Medicaid office, not Medicare. You can find your state office by calling 1-800-MEDICARE or visiting Medicare.gov. Some states let you explore online, by mail, or in person; others use only one method.

When you explore, bring proof of your income (pay stubs, Social Security statements, pension letters), proof of your resources if your state requires it, and your Medicare card. You will also need to report any household members and their income. The process asks whether you want to be considered for all four programs or just one.

Processing time varies by state. Some decisions come within two weeks; others take four to six weeks. If you are approved, your state will send you a Medicaid card and tell you when your coverage starts. If you are denied, the letter will explain why and tell you how to appeal.

What Happens When You See a Doctor or Get Care

When you have Cost-Share Medicaid, show both your Medicare card and your Medicaid card at every appointment. The provider's office will bill Medicare first. After Medicare pays, the office should bill your Medicaid program for the remaining balance.

In most cases, you should not receive a bill if you are in QMB, because QMB covers all copayments and coinsurance. If you are in SLMB, QI, or QDWI, you may still owe copayments or coinsurance that those programs do not cover. Ask your provider's billing office what you will owe before your appointment.

Some providers do not know about Cost-Share Medicaid or do not bill it correctly. If you receive a bill you believe Medicaid should have paid, contact your state Medicaid office. They can follow up with the provider or send you a form to dispute the bill.

Reporting Changes and Keeping Your Coverage Active

You must report changes in your income, household size, or living situation to your state Medicaid office. If your income increases above the limit for your program, you may lose coverage. If you move to a different state, you will need to explore to that state's program because Medicaid is state-run.

Your state will send you a renewal notice before your coverage ends, usually once a year. You must return the renewal form or explore again to keep your coverage. If you do not renew on time, your Medicaid will end and you will owe the full cost of copayments and coinsurance again.

Some states use continuous enrollment, meaning your coverage renews automatically if your situation has not changed. Other states require you to actively renew each year. Your Medicaid office will tell you which process applies where you live.

What Cost-Share Medicaid Does Not Cover

Cost-Share Medicaid only covers costs that Medicare would cover if you had no Medicaid. It does not pay for services Medicare does not cover, such as dental care, vision care, hearing aids, or long-term care in a nursing home. If Medicare does not pay for something, Medicaid will not pay for it either through this program.

Cost-Share Medicaid also does not cover your Medicare Part D prescription drug premium or your out-of-pocket drug costs. If you need help with prescription costs, you may be able to get help through a different Medicaid program or through the Medicare Low-Income Subsidy program.

Frequently Asked Questions

Can I have Cost-Share Medicaid if I am still working?

Yes. Income limits are based on your total household income, not your employment status. If your income is below the limit for your state, you can be enrolled. QDWI is specifically for working people under 65 on Medicare due to disability, but working people can also may have access to for QMB, SLMB, or QI if their income meets the limit.

What if my state says I do not meet the income limit?

Ask your state Medicaid office to check all four programs, not just one. Each program has a different income limit, and you might may have access to for one even if you do not may have access to for another. If you are above all four limits, ask whether your state has other Medicaid programs that might help with medical costs.

Do I lose my Cost-Share Medicaid if my income goes up slightly?

It depends on how much your income increases and which program you are in. Most programs allow a small amount over the limit before coverage ends. When you report an income change, your state will tell you whether you still may have access to. If you lose coverage, you can reapply if your income drops again.

What if my provider will not bill Medicaid?

Providers are required to bill Medicaid when you have both Medicare and Medicaid. If a provider refuses, contact your state Medicaid office and report the provider's name and the date of service. Your state can investigate and require the provider to bill correctly. You can also ask the provider's billing office to submit the claim on your behalf.

Can I switch between the four programs?

No. Your state determines which program you may have access to for based on your income. You cannot choose to be in QMB if you only meet the income limit for SLMB. However, if your income changes, you may become may be able to access for a different program when you renew or report the change.