Medicaid when you're 65 or older and have Medicare

What Medicaid adds on top of Medicare

If you have both, Medicare pays first and Medicaid pays last, after Medicare and any other insurance you have. (The basic difference between the two programs is in Medicare vs Medicaid in New York.) For people 65 and older that usually means three things.

• Your Medicare costs. Medicaid may pay your Part B premium and, depending on how you qualify, some of your Medicare deductibles, coinsurance and copays.
• Care Medicare doesn't normally pay for. Medicaid covers services Medicare usually doesn't, such as personal care and other long-term care at home, and nursing home care.
• Help with drugs. Your prescriptions are still covered through Medicare Part D, not Medicaid, but with both programs you get Extra Help, which lowers the cost of a Part D plan. There's more on that on my Extra Help page.

Medicaid is run by New York State and the county Departments of Social Services. I'm a Medicare agent, so I can explain how the two programs work together, but the county or the state decides whether you qualify.

Full Medicaid or the Medicare Savings Program

These two get mixed up all the time, partly because Medicaid runs both.

If your savings rule out full Medicaid, the Medicare Savings Program is still worth checking: the state says many people who don't qualify for Medicaid because of their resources can qualify for the MSP. The wider picture, including EPIC, is on the help paying for Medicare page.

The income and resource test

Full Medicaid for people 65 and older looks at your monthly income and at your resources, meaning money in the bank and other countable assets. The New York State Department of Health sets both limits and they change every January. I'm not printing the figures here, because the official charts are updated at different times and an old number is worse than none. Here's where to find the current ones:

• The Department of Health's How to Apply page has a chart of income and resource levels for people who are 65 or older, blind or disabled. Check the effective date under the chart.
• The Department sends county offices the new figures each year in its General Information System messages. The 2027 levels will follow the same route after the new year.
• Your county DSS Medicaid unit (links below) can tell you the level that applies to you today.

Two things worth knowing before you add anything up. The state says you may own a home, a car and personal property and still be eligible. And if you're applying for nursing home care or other long-term care at home, expect to show information on bank accounts, insurance policies and other resources.

If your income is over the limit: the Excess Income program

New York has a way in for people whose income is above the Medicaid level. It's called the Excess Income program, and you'll also hear "spend-down" or "surplus income." It's open to people 65 and older, among others.

• The amount your countable income is over the Medicaid level is your excess income. Your caseworker works it out and sends you a notice.
• It works like a deductible. Once your medical bills in a month reach that amount, Medicaid pays for covered care for the rest of the month. There's also a six-month option that includes hospital care.
• The bills can be paid or unpaid. Doctor visits, prescriptions, transportation to appointments and the Medicare deductibles and copays you owe all count; with Medicare, only the part Medicare doesn't pay counts. Bills that EPIC paid can count too.
• If you don't have enough bills in a month, you can pay the excess amount to the county instead (the Pay-In option). The state says to do that only in months you need care.
• Once you've met the amount, Medicaid pays only providers who are enrolled in New York Medicaid, so check that yours are.

You join through your county Department of Social Services. The Department of Health's Excess Income page goes through the rules on older bills and family members' bills.

Where to apply

This has changed in the last few years, and the state's and counties' websites don't all say the same thing yet. According to the Department of Health:

• NY State of Health now handles Medicaid for many people with Medicare, including people with both Medicare and Medicaid, people 65 and older who aren't seeking long-term care, and people applying for the Medicare Savings Program.
• Your county Department of Social Services handles the Excess Income (spend-down) program, community-based long-term care, people receiving SSI, and others. Paper applications for this group use form DOH-4220.

The state also says that wherever you start, the people there will make sure you apply in the right place. If you're unsure, I'd call the county Medicaid unit first. Free in-person help is also available from the state's Facilitated Enrollers for the Aged, Blind and Disabled.

County Departments of Social Services

• Albany County
• Rensselaer County
• Saratoga County
• Schenectady County
• Warren County
• Washington County

The state keeps the full list on its local Departments of Social Services page. The New York Medicaid Helpline is (800) 541-2831.

How Medicaid and your Medicare coverage fit together

Once you have Medicaid, you still choose how to get your Medicare benefits.

• Original Medicare with Medicaid behind it. Medicare pays first, Medicaid picks up what it covers, and a Part D plan with Extra Help handles your drugs.
• A Dual Eligible Special Needs Plan (D-SNP). A type of Medicare Advantage plan for people with both Medicare and Medicaid, which coordinates the two. How they work in New York, and when you can switch, is in my guide to Medicare and Medicaid together.
• Medicare Savings Program only. If you qualify for the MSP but not full Medicaid, you keep whatever Medicare coverage suits you and the MSP pays part of the cost. See the MSP page.

One rule to know if you're close to 65: New York can require you to apply for Medicare as a condition of getting Medicaid, when Medicaid would pay your Medicare premiums. The state accepts your Social Security award letter or online application confirmation as proof.

Where I can help

I can look at the Medicare side with you: whether the Medicare Savings Program or Extra Help is worth applying for, how your current plan would work alongside Medicaid, and whether a D-SNP or Original Medicare suits you better once Medicaid is in place. For the Medicaid application itself, the county office and the state's facilitated enrollers are the right people, and the county HIICAP counselors give free, unbiased Medicare advice too. If you'd like to talk it through, get in touch.

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