Paul Sanchez
Medicaid is a federal program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Each state has its own criteria and coverage for Medicaid, and eligibility does not transfer from one state to another. If you have Medicaid and other health insurance or coverage, each type of coverage is called a payer. When there is more than one payer, coordination of benefits rules decide which one pays first. To ensure the correct payment of your claims, you should respond to the Medicare Secondary Claim Development Questionnaire letters and inform the Benefits Coordination & Recovery Center (BCRC) about any changes in your health insurance.
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What You'll Learn
Medicaid and Medicare
Medicaid is a means-tested program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. The eligibility criteria and coverage provided by Medicaid vary from state to state, and individuals must meet their state's rules regarding income and resources to qualify. In 2023, Medicaid covered nearly 4 in 10 children, over 8 in 10 children in poverty, 1 in 6 adults, and almost half of adults in poverty. It is a significant source of funding for the US healthcare system, covering 19% of all healthcare spending and hospital spending. In addition to mandatory benefits, states can choose to cover optional benefits like prescription drugs and home care. Other benefits not usually covered by health insurance include non-emergency medical transportation and comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services.
Medicare, on the other hand, is a federal program that provides health insurance to individuals aged 65 or older and those with certain disabilities. Unlike Medicaid, eligibility for Medicare is not based on income or state-specific criteria. Medicare works in conjunction with other health insurance or coverage that an individual might have. In such cases, coordination of benefits rules decide which insurance pays first. The primary payer pays what it owes on the bills first, and then the remaining amount is sent to the secondary payer to cover.
Individuals enrolled in Medicaid may also have additional sources of coverage for healthcare services. This is known as Third-Party Liability (TPL), where third parties, such as insurers or programs, are legally obligated to pay for medical assistance provided under a Medicaid state plan. States are responsible for identifying potentially liable third parties and conducting data matches to determine if a Medicaid enrollee has coverage through other sources, such as the Military Health Services system or automobile insurance policies.
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Medicaid and private insurance
Medicaid is a federal program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. However, the criteria and coverage vary from state to state, and eligibility in one state does not transfer to another. For instance, if you have Medicaid in one state and move to Virginia, you must apply for Virginia Medicaid separately and meet its specific guidelines.
It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for healthcare services. This includes private insurance, Medicare, other public programs such as the Ryan White program, workers' compensation, and amounts received for injuries in liability cases. When Medicaid beneficiaries have other sources that are legally liable for their medical costs, it is referred to as Third Party Liability (TPL). By law, all available third-party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an eligible individual.
Coordination of Benefits (COB) comes into play when determining Medicaid benefits for enrollees with other sources of coverage. In such cases, enrollees with other insurance coverage are typically enrolled in managed care, and the state retains TPL responsibilities. States conduct data matches with entities like the Department of Defense to identify enrollees with coverage through programs like the Military Health Services system and TRICARE. Additionally, state child support agencies must notify the Medicaid agency when a parent acquires health coverage for their child through a court order.
It's important to note that having Medicaid and being enrolled in a federal Advance Premium Tax Credit (APTC) health insurance program is prohibited. If approved for Medicaid, you cannot cancel your coverage to receive a tax credit, and vice versa.
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Medicaid and job-related health insurance
Medicaid is a federal program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility criteria and coverage vary from state to state, and it is not tied to one's job. This means that even if you lose your job, you will still have Medicaid. However, if you find a new job, your changed financial situation will determine whether you remain eligible for Medicaid.
If you have job-based insurance, you will not qualify for savings on a Marketplace plan. In 2025, a job-based health plan is considered "affordable" if your share of the monthly premium in the lowest-cost plan offered by the employer is less than 9.02% of your household income. If your employer's plan meets this standard, you will not qualify for a premium tax credit if you buy a Marketplace insurance plan instead.
It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for healthcare services. If you have Medicaid and job-based insurance, each type of coverage is called a "payer". The primary payer pays what it owes on your bills first, and then sends the rest to the "secondary payer" to pay. The secondary payer only pays if there are costs the primary payer didn't cover.
When applying for Medicaid, you must provide information about any job-related health insurance available to you and your family. This is because states are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan.
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Medicaid and health insurance for children
Medicaid is a federal program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. However, it's important to note that Medicaid criteria, coverage, and eligibility vary from state to state, and eligibility in one state does not transfer to another.
Medicaid and the Children's Health Insurance Program (CHIP) work together to provide free or low-cost health coverage to children. CHIP is a state-managed program that provides health coverage to eligible children from families with incomes too high to qualify for Medicaid but too low to afford private coverage. It is funded by both the states and the federal government.
Each state has its own rules for CHIP eligibility, and the benefits offered may differ as well. Some states, for example, cover routine "well child" doctor and dental visits for free under CHIP. It's important to check with your state to understand the specific covered services and benefits.
In addition to CHIP, some children may be eligible for Medicaid directly. This is often the case for children in low-income families who meet their state's Medicaid income guidelines. Even if you don't think your income qualifies, it's worth applying because each state's Medicaid program has unique criteria, and you may be eligible for your state's program, especially if you have children.
It is possible for Medicaid beneficiaries to have additional sources of health care coverage. This is known as Coordination of Benefits (COB) and involves determining Medicaid benefits when an enrollee has other insurance coverage. In these cases, third parties, such as insurers, may be liable to pay for services before the Medicaid program pays for the care of an eligible individual.
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Medicaid and health insurance for seniors
Medicaid is a federal program that offers health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. However, it's important to note that Medicaid criteria and coverage vary from state to state, and eligibility in one state does not transfer to another. For example, in Texas, seniors without health insurance may be able to obtain coverage through the Medicaid for the Elderly and People with Disabilities program.
Medicaid beneficiaries can have additional sources of coverage for healthcare services. This is referred to as Third-Party Liability (TPL), where third parties, such as insurers or programs, are legally obligated to pay for medical assistance provided under a Medicaid state plan. States are required to identify these third parties and ensure they meet their payment obligations before the Medicaid program pays for the care of an eligible individual.
When an individual has both Medicaid and other insurance coverage, "coordination of benefits" rules determine which insurance pays first. The primary payer covers expenses up to the limits of its coverage, and any remaining costs are sent to the secondary payer. To ensure correct payment, individuals should inform their healthcare providers about their coverage and respond to the Medicare Secondary Claim Development Questionnaire, which collects information about other insurers that may pay before Medicare.
Medicare is a federal program that provides health insurance to individuals aged 65 and older, certain people with disabilities, and those with end-stage renal disease (ESRD). It has different parts, including Part B, which covers physician services, lab and x-ray services, and durable medical equipment; and Part D, which assists with prescription drug costs. About 12 million people are enrolled in both Medicare and Medicaid, and Medicaid can help cover premiums and out-of-pocket expenses for those with limited incomes.
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Frequently asked questions
You can apply for Medicaid by calling your state's Medicaid Call Center or by mailing a paper application to your local Department of Social Services office. You can also apply online.
No, you do not need to have insurance to apply for Medicaid. However, you will need to provide information on any current health insurance and job-related health insurance available to you and your family.
No, federal regulations prohibit being enrolled in Medicaid and receiving an Advanced Premium Tax Credit (APTC).
You will need to fill out a Medicare Secondary Claim Development Questionnaire, which will be sent to you when you make a claim. You will also need to inform your doctor and other healthcare providers.
