Medicare and Medicaid Together: Home Care for Dual-Eligible New Yorkers
Having both programs is the best position an older New Yorker can be in for home care, and the most confusing. Here is who pays for what, and how to get daily hours without the two programs pointing at each other.
For a person with both Medicare and Medicaid (“dual eligible”), Medicare pays for short-term skilled care after illness or surgery (visiting nurse, therapy, limited aide visits), and Medicaid pays for ongoing daily home care hours through an MLTC or integrated plan. Medicare is billed first for what it covers; Medicaid covers the rest, generally with no out-of-pocket cost for home care. Advantage Home Care works with both and helps families enroll in the right plan at no charge. Call 718-375-2707.
Two Programs, Two Jobs
Medicare is health insurance for people 65 and over and some younger people with disabilities. It is good at hospitals, doctors and short recoveries, and it does not pay for long-term daily help at home. Medicaid is the state and federal program for people with limited income and resources, and in New York it is the program that pays for ongoing home health aides and personal care aides. A person who has both gets Medicare’s medical coverage and Medicaid’s long-term care coverage, with Medicaid also picking up most Medicare premiums and cost-sharing. The confusion comes at the boundary: after a hospital stay, Medicare’s home health benefit starts, and families assume that is “the home care,” then it ends after a few weeks and they are left without help. The Medicaid side has to be set up separately.
Who Pays for What
Hospital and doctor care; short-term skilled home health after illness or surgery (nurse, PT/OT, limited aide visits tied to skilled care); hospice; some equipment.
Ongoing home health aide and personal care hours; long-term equipment and supplies; Medicare premiums and most cost-sharing; transportation to medical appointments.
Medicare is billed first for anything it covers; Medicaid pays after. The agency and the plan handle this, not the family.
For dual-eligible people, home care hours are generally covered with no copay; a spend-down or pooled income trust applies only if income is over the Medicaid limit.
Getting Daily Hours as a Dual-Eligible Person
- Enroll in a long-term care plan. Under current New York rules, most dual-eligible adults who need ongoing home care join a Managed Long Term Care (MLTC) plan for the Medicaid side, or an integrated plan that combines Medicare and Medicaid coverage in one card. Which fits depends on the person’s doctors and needs; see how to choose an MLTC plan.
- Complete the assessment. The independent assessment and the plan’s nurse visit set the hours; see how the assessment decides your hours.
- Use Medicare’s home health at the same time. After a hospital stay, Medicare’s nurse and therapy visits can run alongside Medicaid aide hours; tell each about the other.
- Keep both renewed. Medicaid eligibility is recertified yearly; see how to keep your hours year after year.
Common Mix-Ups
“Medicare will cover an aide.” Only briefly and only alongside skilled care; see does Medicare pay for home care? “We have a Medicare Advantage plan, so we are set.” Advantage plans may offer small supplemental benefits, but daily hours still come through Medicaid. “Medicaid will make us sell the house.” Under current New York rules a primary home is generally treated differently from savings for Community Medicaid; ask before assuming. “One card covers everything.” Only if the person is in an integrated plan; otherwise there are two cards and two sets of rules, and the agency helps keep them straight.
Related Guides
How many hours of Medicaid home care can you get? Β· What home care services Medicaid covers Β· Medicare vs Medicaid for home care Β· Home care vs home health care
Frequently Asked Questions
If my mother has Medicare and Medicaid, who pays for her home health aide?
Medicaid, through her MLTC or integrated plan, for ongoing daily hours; Medicare only for short-term skilled care after illness or surgery.
Is there any cost for home care when someone is dual eligible?
Generally no copay for the hours; a monthly spend-down or pooled income trust applies only if income is over the Medicaid limit.
Can Medicare home health and Medicaid aide hours run at the same time?
Yes. Nurse and therapy visits from Medicare can overlap with Medicaid aide hours; make sure each knows about the other.
Does a Medicare Advantage plan replace the need for Medicaid home care?
No. Some Advantage plans offer limited extras, but daily home care hours come through Medicaid.
What is an integrated plan?
A plan that combines Medicare and Medicaid coverage under one card and one care manager; whether it suits your parent depends on doctors and needs, and we can walk through the options.
How fast can hours start once enrolled?
Once the plan authorizes hours, care often starts within days; private-pay hours can bridge any gap.
Get Both Programs Working for You
Tell us what coverage your loved one has. We will explain what each program pays for, help with plan enrollment, and start care as soon as hours are authorized.
Call 718-375-2707Start Home Care