Medicare and Medicaid in Texas: Dual Eligibility

Some Texans qualify for both Medicare and Medicaid. This is called dual eligibility. Having both programs can reduce healthcare expenses and may provide access to services beyond Original Medicare, but the benefits depend on your exact Medicaid eligibility category.

Medicare and Medicaid are separate programs, and being eligible for one does not automatically mean you qualify for the other.

Medicare versus Medicaid

Medicare is federal health insurance primarily for people age 65 and older and certain younger people with disabilities or qualifying conditions. Medicaid is a federal-state program that helps eligible people with limited income and resources obtain healthcare coverage.

Texas administers Medicaid through Texas Health and Human Services. Read who qualifies for Medicare and Texas Health and Human Services.

Full versus partial dual eligibility

A full-benefit dual-eligible beneficiary qualifies for Medicare and a full Medicaid benefit package under the applicable Texas program. A partial-benefit dual-eligible beneficiary may receive only help paying certain Medicare expenses through a Medicare Savings Program.

For example, SLMB generally helps pay the Part B premium but does not automatically provide long-term care services. QMB has broader Medicare-covered cost-sharing protections. See Texas Medicare Savings Programs.

Which program pays first?

For services covered by Medicare, Medicare generally processes the claim first. Medicaid may then assist with eligible remaining expenses, subject to Texas payment rules and the beneficiary's Medicaid category.

Some services may be covered by Medicaid but not Original Medicare, and those services follow Medicaid program requirements. Do not assume every bill is automatically zero. Verify provider participation, covered services and any required authorization.

See Medicare Part A and Medicare Part B.

What QMB means for medical bills

QMB provides important protection against billing for Medicare-covered deductibles, copayments and coinsurance. Providers generally cannot charge QMB beneficiaries these Medicare-covered amounts, even if the provider is not enrolled in Medicaid.

This is different from the benefits available through SLMB or QI alone. If you receive a bill for covered cost sharing, ask the provider to verify your QMB status before paying.

Long-term care and Texas Medicaid

Original Medicare generally does not pay for ongoing custodial care solely because a person needs help with everyday activities. Certain Texas Medicaid programs may cover qualifying nursing facility care, personal assistance and other long-term services and supports.

Eligibility and services vary. Texas operates managed care arrangements including STAR+PLUS for certain eligible older adults and people with disabilities. Ask Texas Health and Human Services which program applies rather than assuming ordinary Medicare benefits include long-term custodial care.

Can you have Medicare Advantage and Medicaid?

Yes. Some dual-eligible beneficiaries enroll in Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs). D-SNPs are designed for qualifying people with both Medicare and Medicaid and may coordinate benefits.

Availability and eligibility vary by county, Medicaid status and plan. Check doctors, hospitals, prescriptions, networks and Medicaid service coordination before enrolling. Compare Original Medicare and Medicare Advantage in Texas.

How prescription drug coverage works

Medicare Part D generally provides outpatient prescription coverage for people with Medicare, including those who also qualify for Medicaid. Medicaid eligibility generally brings Extra Help with Part D expenses.

However, formularies, preferred pharmacies and medication restrictions still vary by plan. Review Extra Help and Part D coverage before changing drug coverage.

Do you need a Medicare Supplement policy?

Federal law generally restricts the sale of Medigap policies to people with Medicaid, subject to limited exceptions. Some Medicaid beneficiaries already receive assistance with Medicare cost sharing that overlaps with Medigap benefits.

For people under 65, eligibility and available Medigap options can differ. See Medigap for People Under 65 in Texas.

Before considering Medigap, confirm whether you have full Medicaid, QMB, SLMB, QI or another category and whether a private policy is appropriate. See Medicare.gov's Medigap information and Medicare Savings Programs at Medicare.gov.

How to apply for Texas Medicaid

Apply through Your Texas Benefits or contact Texas Health and Human Services.

The state may request proof of Medicare coverage, residency, income, financial resources and other eligibility factors. If you need nursing facility services or help with activities of daily living, make sure your application is evaluated for the relevant Medicaid long-term services program rather than only Medicare premium assistance.

Keep copies of the application and decision notices.

What happens if you lose Medicaid?

A change in income, resources, residency or other circumstances can affect eligibility. Loss of Medicaid may create Medicare Special Enrollment Period rights depending on the event, and certain coverage changes may involve separate Medigap protections.

Keep your formal termination notice, check the deadlines and contact the state promptly. Do not assume every Medicaid loss gives an unrestricted right to buy any Medigap policy. See Medicare's Special Enrollment Period guidance and Texas guaranteed-issue rights.

Frequently asked questions