How Medicaid and Medicare Advantage Plans Work Together

Medicare Advantage and Medicaid are separate programs that can cover you at the same time

If you have both Medicare and Medicaid, your Medicare Advantage plan is your primary insurance — it pays first for covered services. Medicaid then acts as a secondary payer and covers costs that Medicare Advantage does not, such as copayments, coinsurance, and services Medicare does not cover at all. This combination is sometimes called "dual coverage" or being "dually may be able to access."

The way the two programs coordinate depends on your state, your specific Medicaid program, and which Medicare Advantage plan you choose. Not all Medicare Advantage plans accept people with Medicaid, and not all states have the same rules about how the two programs work together. Understanding which plan will work with your Medicaid coverage is the first step.

Key Takeaways

• Medicare Advantage is your primary insurance and pays first; Medicaid covers what Medicare Advantage leaves unpaid, including copays and services Medicare does not cover.
• Not every Medicare Advantage plan accepts Medicaid members, so you must check with the plan directly before enrolling to confirm they cover people in your state with your type of Medicaid.
• Your state Medicaid program sets rules about which services Medicaid will pay for when you have Medicare Advantage, and these rules vary widely by state.
• If you lose Medicaid, you may be able to switch Medicare Advantage plans outside the normal enrollment period, so report any changes to your Medicaid status when ready.
• Dual-may be able to access special needs plans (D-SNPs) are Medicare Advantage plans designed specifically for people with both Medicare and Medicaid.

Which Medicare Advantage plans accept Medicaid members

Most large Medicare Advantage insurers offer at least one plan in most states that will accept people with Medicaid. However, acceptance varies by state and by the type of Medicaid you have. Some plans accept only people on Medicaid for the elderly or disabled; others accept people on Medicaid for low-income families. A few plans do not accept Medicaid members at all.

Before you enroll in any Medicare Advantage plan, call the plan's customer service number and ask directly: "Do you accept members who also have Medicaid in [your state]?" Have your Medicaid card ready and be prepared to describe which Medicaid program you are in. If the plan says no, move to the next option. If the plan says yes, ask them to confirm in writing or send you a letter stating they accept your type of Medicaid coverage.

The easiest way to find plans that accept Medicaid is to use the Medicare Plan Finder tool on Medicare.gov and filter for your state. You can also call 1-800-MEDICARE and ask the representative to identify plans in your area that accept Medicaid members.

How Medicaid pays when you have Medicare Advantage

Once Medicare Advantage pays its share of a bill, Medicaid looks at what remains. If your state's Medicaid program covers that service, Medicaid will usually pay the copayment, coinsurance, or deductible that Medicare Advantage left you responsible for. Medicaid may also cover services that Medicare Advantage does not cover — such as dental, vision, or hearing aids — if your state's Medicaid program includes those benefits.

The catch is that your state decides what Medicaid will and will not pay for when you have Medicare Advantage. Some states are generous and cover most out-of-pocket costs. Other states cover only the copayments and coinsurance for services Medicare covers, and nothing else. A few states have limits on how much Medicaid will pay toward Medicare Advantage copays in a given year.

You can find your state's specific rules by calling your state Medicaid office or by visiting your state's Medicaid website. Ask them: "If I have Medicare Advantage and Medicaid, what will Medicaid pay for?" Write down the answer and keep it with your insurance cards.

Dual-may be able to access special needs plans (D-SNPs)

Medicare offers a category of Medicare Advantage plans called Dual-may be able to access Special Needs Plans (D-SNPs) that are designed specifically for people with both Medicare and Medicaid. These plans are required to coordinate with Medicaid and often include extra benefits that regular Medicare Advantage plans do not, such as transportation to medical appointments or meal delivery.

D-SNPs are available in most states but not all. To enroll in a D-SNP, you must be enrolled in both Medicare and Medicaid at the time you join. If you are interested in a D-SNP, ask your state Medicaid office whether D-SNPs are available in your state and which insurers offer them. You can also search for D-SNPs on Medicare.gov by selecting your state and looking for plans labeled as "Special Needs Plans."

D-SNPs often have lower or no premiums, lower copayments, and more comprehensive coverage than standard Medicare Advantage plans. However, they may have narrower networks of doctors and hospitals, so check whether your current providers are in the plan's network before you enroll.

What happens if you lose Medicaid

If your Medicaid coverage ends for any reason — because your income increased, you moved to a different state, or you no longer meet your state's requirements — you lose the secondary coverage that was paying your copays and coinsurance. This is a major change to your insurance situation and can trigger a special enrollment period that allows you to switch Medicare Advantage plans outside the normal October to December window.

When you lose Medicaid, contact your Medicare Advantage plan when ready and tell them. Ask whether losing Medicaid qualifies you for a special enrollment period. If it does, you have 60 days from the date your Medicaid ends to switch to a different Medicare Advantage plan or to Original Medicare. If you do not act within 60 days, you will be locked into your current plan until the next open enrollment period in October.

Report any changes to your Medicaid status to Medicare as well. You can update your information by calling 1-800-MEDICARE or by logging into your Medicare.gov account online.

Network and provider rules when you have both programs

Your Medicare Advantage plan has a network of doctors, hospitals, and specialists that it covers. When you have Medicaid as well, you must use providers in your Medicare Advantage plan's network for Medicaid to pay its share. If you see a provider outside the network, Medicare Advantage will not pay, and Medicaid usually will not pay either — even if that provider accepts Medicaid.

Before you enroll in a Medicare Advantage plan, check whether your current doctors and hospitals are in the plan's network. You can do this on the plan's website or by calling the plan's customer service number. Ask specifically: "Is [doctor name] in your network?" and "Is [hospital name] in your network?" If your main providers are not in the network, you may need to choose a different plan or be prepared to switch doctors.

Some Medicare Advantage plans allow you to see out-of-network providers for a higher cost, but Medicaid will not cover that extra cost. You will pay the full bill yourself.

Prescription drug coverage with Medicare Advantage and Medicaid

All Medicare Advantage plans include prescription drug coverage (Part D). When you have Medicaid as well, your Medicare Advantage plan pays for drugs first, and Medicaid covers the copayments and coinsurance that the plan leaves you responsible for. Some states also allow Medicaid to cover drugs that Medicare Advantage does not cover, though this varies widely.

Make sure the medications you take are on your Medicare Advantage plan's formulary — the list of drugs the plan covers. You can check the formulary on the plan's website or by calling the plan's pharmacy department. If a medication you need is not on the formulary, ask whether the plan will make an exception or whether you can request a prior authorization.

If your Medicaid program covers a drug that your Medicare Advantage plan does not, contact your state Medicaid office to ask whether they will pay for it. The answer depends on your state's rules and on whether the drug is on your state's Medicaid formulary.

Frequently Asked Questions

Can I have Medicare Advantage and Medicaid at the same time?

Yes. If you are enrolled in both Medicare and Medicaid, you can enroll in a Medicare Advantage plan. Medicare Advantage becomes your primary insurance, and Medicaid covers costs that Medicare Advantage does not. However, not all Medicare Advantage plans accept Medicaid members, so you must confirm with the plan before enrolling.

What if my Medicare Advantage plan does not accept Medicaid?

If you enroll in a Medicare Advantage plan that does not accept Medicaid members, you will still have Medicaid, but the plan may not coordinate with it properly and may not know you have it. This can cause billing problems and confusion. Always confirm before enrolling that the plan accepts Medicaid in your state.

Do I have to choose a D-SNP if I have Medicare and Medicaid?

No. D-SNPs are designed for people with both programs, but you can also enroll in a regular Medicare Advantage plan if one is available in your area that accepts Medicaid. Compare the benefits, costs, and networks of both types of plans before deciding.

What happens to my Medicaid if I switch Medicare Advantage plans?

Your Medicaid coverage does not change when you switch Medicare Advantage plans. Medicaid remains your secondary insurance and continues to cover copays and other costs that your new plan does not cover. However, you should notify your state Medicaid office of the change so their records are accurate.

Can Medicaid pay for services that Medicare Advantage does not cover?

It depends on your state. Some states allow Medicaid to cover services that Medicare Advantage does not, such as dental or vision care. Other states cover only the copayments and coinsurance for services Medicare covers. Contact your state Medicaid office to learn what your state covers.