Medicare vs. Medicaid in Texas: Understanding the Key Differences

Understanding the difference between Medicare vs. Medicaid in Texas is essential for making informed healthcare coverage decisions. While both programs provide vital healthcare coverage, they serve different populations, offer different benefits, and operate under different rules. Many Texas residents are confused about which program they qualify for or whether they can have both types of coverage simultaneously.

Medicare and Medicaid differences go far beyond just eligibility requirements – they encompass funding sources, covered services, provider networks, and costs. Some fortunate individuals may qualify for both programs, creating opportunities for comprehensive coverage but also complex coordination between federal and state systems.

This comprehensive guide explains exactly how Medicare and Medicaid work in Texas, who qualifies for each program, what services they cover, and how they can work together. Whether you’re approaching Medicare eligibility or facing financial hardship that might qualify you for Medicaid, understanding these programs is crucial for securing the healthcare coverage you need.

What is Medicare? Federal Health Insurance for Seniors and Disabled

Medicare is a federal health insurance program primarily serving Americans aged 65 and older, along with certain younger individuals with disabilities or specific medical conditions. Administered by the Centers for Medicare & Medicaid Services (CMS), Medicare provides standardized benefits across all 50 states, including Texas.

Medicare Eligibility Requirements

Age-Based Eligibility:

• 65 years or older
• Eligible for Social Security or Railroad Retirement benefits
• U.S. citizen or legal permanent resident for at least 5 years

Disability-Based Eligibility:

• Under 65 with qualifying disabilities
• Receiving Social Security Disability Insurance (SSDI) for 24 months
• End-Stage Renal Disease (ESRD) at any age
• Amyotrophic Lateral Sclerosis (ALS) with no waiting period

Work History Requirements:

• You or your spouse must have worked and paid Medicare taxes for at least 40 quarters (10 years)
• Premium-free Part A hospital insurance for those meeting work requirements
• Part B and Part D available for purchase regardless of work history

The Four Parts of Medicare

Medicare Part A (Hospital Insurance):

• Inpatient hospital care
• Skilled nursing facility care
• Home health services
• Hospice care
• Premium-free for most beneficiaries

Medicare Part B (Medical Insurance):

• Doctor visits and outpatient care
• Medical equipment and supplies
• Preventive services
• Standard monthly premium ($185 in 2026)

Medicare Part C (Medicare Advantage):

• Private insurance alternative to Original Medicare
• Includes Part A, Part B, and usually Part D
• May offer additional benefits like dental and vision
• Different rules and networks than Original Medicare

Medicare Part D (Prescription Drug Coverage):

• Prescription drug coverage through private plans
• Required to avoid late enrollment penalties
• Works with Original Medicare and Medicare Supplement plans
• Available as standalone plans or included in Medicare Advantage

What is Medicaid? State-Federal Partnership for Low-Income Healthcare

Medicaid is a state-federal partnership program that provides healthcare coverage for low-income individuals and families. In Texas, Medicaid is administered by the Texas Health and Human Services Commission (THHSC) under federal guidelines but with state-specific rules and benefits.

Texas Medicaid Eligibility Categories

Children and Families:

• Children in families with income up to 201% of Federal Poverty Level (FPL)
• Pregnant women up to 185% FPL
• Parents and caretaker relatives with significantly lower income limits

Elderly and Disabled Adults:

• Age 65 or older with limited income and resources
• Adults with disabilities receiving Supplemental Security Income (SSI)
• Individuals requiring long-term care services
• Certain adults with serious mental illness or intellectual disabilities

Texas-Specific Medicaid Programs:

• STAR Program: Managed care for most Medicaid recipients
• STAR+PLUS: For adults with disabilities and long-term care needs
• STAR Kids: Specialized program for children with disabilities
• STAR Health: For children in foster care

Texas Medicaid Income Limits (2026)

Category	Individual Monthly Income	Couple Monthly Income	Asset Limit
Aged (65+)	$943	$1,281	$2,000 / $3,000
Disabled Adults	$943	$1,281	$2,000 / $3,000
Pregnant Women	$2,832 (185% FPL)	N/A	No limit
Children (0-18)	$3,077 (201% FPL)	N/A	No limit
Parents/Caretakers	$334 (22% FPL)	$453 (22% FPL)	$2,000 / $3,000

Important Note: Texas has not expanded Medicaid under the Affordable Care Act, leaving many low-income adults without coverage options.

How Texas Medicaid Works

Managed Care Delivery:

• Most Texas Medicaid recipients receive services through managed care organizations (MCOs)
• Members choose from approved health plans in their region
• Plans coordinate care and manage provider networks
• Different MCOs serve different regions of Texas

Fee-for-Service Exception:

• Some services paid directly by Texas Medicaid
• Emergency services during managed care transition
• Certain specialized services not covered by MCOs
• Out-of-network emergency situations

Key Differences: Medicare vs. Medicaid Comparison

Understanding the fundamental differences between Medicare and Medicaid helps clarify which program might serve your needs and how they can work together.

Program Structure and Administration

Aspect	Medicare	Medicaid
Administration	Federal program (CMS)	State-federal partnership (THHSC)
Funding	Federal payroll taxes + premiums	Federal and state taxes
Eligibility	Age 65+ or disability	Low income and assets
Standardization	Nationally standardized benefits	State-specific programs and benefits
Provider Payment	Higher reimbursement rates	Lower reimbursement rates

Coverage and Benefits Comparison

Service Type	Medicare Coverage	Texas Medicaid Coverage
Hospital Care	Part A covers inpatient stays	Full coverage with no deductible
Doctor Visits	Part B covers 80% after deductible	Full coverage with managed care
Prescription Drugs	Part D with cost-sharing	Covered with small copayments
Long-term Care	Limited skilled nursing coverage	Comprehensive long-term care
Dental Care	Limited emergency dental only	Basic dental services included
Vision Care	Limited to medical eye conditions	Basic vision services included
Transportation	No coverage	Medical transportation provided
Mental Health	Covered with cost-sharing	Comprehensive mental health services

Cost Structure Differences

Medicare Costs:

• Part A: Premium-free for most, deductibles and coinsurance apply
• Part B: Standard premium $185/month (2026), 20% coinsurance
• Part D: Premiums vary, deductibles, coverage gap, coinsurance
• Out-of-pocket limits: No annual limit with Original Medicare

Texas Medicaid Costs:

• Premiums: Generally no monthly premiums
• Copayments: Small copayments for some services ($3-5 typical)
• Deductibles: No deductibles for covered services
• Out-of-pocket protection: Minimal costs for covered services

Dual Eligible: Having Both Medicare and Medicaid

Approximately 12% of Medicare beneficiaries are dual eligible, meaning they qualify for both Medicare and Medicaid coverage. This dual coverage can provide comprehensive healthcare benefits but requires understanding how the programs coordinate.

Who Qualifies as Dual Eligible in Texas?

Full Dual Eligible:

• Age 65+ or disabled AND meet Medicaid income/asset limits
• Receive full benefits from both programs
• Medicare pays first, Medicaid pays Medicare costs
• Access to additional Medicaid services not covered by Medicare

Partial Dual Eligible (Medicare Savings Programs):

• Income slightly above Medicaid limits but still low
• Medicaid helps pay Medicare premiums, deductibles, and coinsurance
• Don’t receive full Medicaid benefits
• Several different assistance levels available

Medicare Savings Programs in Texas

Qualified Medicare Beneficiary (QMB):

• Income limit: 100% FPL ($1,530 individual, $2,072 couple monthly in 2026)
• Asset limit: $9,430 individual, $14,130 couple
• Benefits: Pays Medicare Part A/B premiums, deductibles, coinsurance

Specified Low-Income Medicare Beneficiary (SLMB):

• Income limit: 120% FPL ($1,836 individual, $2,486 couple monthly)
• Asset limit: Same as QMB
• Benefits: Pays Medicare Part B premium only

Qualifying Individual (QI):

• Income limit: 135% FPL ($2,065 individual, $2,797 couple monthly)
• Asset limit: Same as QMB
• Benefits: Pays Medicare Part B premium (subject to federal funding)

Qualified Disabled Working Individual (QDWI):

• Income limit: 200% FPL ($3,060 individual, $4,144 couple monthly)
• Asset limit: $4,000 individual, $6,000 couple
• Benefits: Pays Medicare Part A premium for working disabled individuals

How Dual Coverage Works

Coordination of Benefits:

1. Medicare pays first for services covered by both programs
2. Medicaid pays Medicare costs including premiums, deductibles, coinsurance
3. Medicaid covers additional services not included in Medicare
4. No gaps in coverage for dual eligible beneficiaries

Additional Medicaid Benefits for Dual Eligible:

• Long-term care services and supports
• Dental, vision, and hearing services
• Medical transportation
• Personal care services
• Home and community-based services
• Prescription drug coverage coordination

Special Needs Plans for Dual Eligible

Dual Eligible Special Needs Plans (D-SNPs):

• Medicare Advantage plans designed specifically for dual eligible individuals
• Coordinate Medicare and Medicaid benefits in one plan
• Often provide additional benefits beyond standard Medicare
• Must accept all dual eligible individuals in their service area

Benefits of D-SNPs:

• Simplified coverage with one plan and one card
• Care coordination between Medicare and Medicaid services
• Additional benefits like transportation and meal delivery
• Specialized provider networks familiar with dual eligible needs

Texas Health and Human Services Commission (THHSC) Role

The Texas Health and Human Services Commission (THHSC) plays a crucial role in administering Medicaid and coordinating with Medicare for dual eligible individuals in Texas.

THHSC Responsibilities

Medicaid Program Administration:

• Determine Medicaid eligibility for Texas residents
• Manage contracts with Medicaid managed care organizations
• Oversee quality and performance of Medicaid services
• Process Medicaid applications and renewals

Medicare Coordination:

• Determine eligibility for Medicare Savings Programs
• Coordinate care for dual eligible beneficiaries
• Work with CMS on federal Medicare policies affecting Texas residents
• Provide information and assistance for Medicare-Medicaid coordination

Long-term Services and Supports:

• Administer nursing home and community-based services
• Coordinate with Medicare for post-acute care services
• Manage waiver programs for home and community-based services
• Oversee quality of long-term care providers

THHSC Regional Offices

THHSC operates regional offices throughout Texas to serve local communities:

Major Metropolitan Regions:

• Houston Region: Harris County and surrounding areas
• Dallas Region: Dallas, Collin, Denton counties and surrounding areas
• San Antonio Region: Bexar County and South Central Texas
• Austin Region: Travis County and Central Texas
• Fort Worth Region: Tarrant County and North Central Texas

Rural and Border Regions:

• East Texas Region: Tyler, Longview, and surrounding rural areas
• West Texas Region: El Paso, Lubbock, and West Texas counties
• Rio Grande Valley: South Texas border counties
• Panhandle Region: Amarillo and Texas Panhandle counties

Applying for Medicaid Through THHSC

Application Methods:

• Online: Through YourTexasBenefits.com
• Phone: 2-1-1 Texas for application assistance
• In-person: Local THHSC offices
• Mail: Paper applications available

Required Documentation:

• Proof of identity and citizenship/immigration status
• Income verification (pay stubs, Social Security statements)
• Asset documentation (bank statements, property records)
• Medical records for disability determinations

Processing Times:

• Standard applications: Up to 45 days for aged/disabled determinations
• Expedited processing available for urgent medical needs
• Hospital presumptive eligibility for emergency situations

Long-term Care: Medicare vs. Medicaid Coverage

Long-term care represents one of the most significant differences between Medicare and Medicaid, with important implications for Texas seniors and their families.

Medicare Long-term Care Coverage

What Medicare Covers:

• Skilled nursing facility care up to 100 days per benefit period
• Home health services for skilled care needs
• Hospice care for terminal conditions
• Inpatient rehabilitation for recovery after hospital stays

Medicare Long-term Care Limitations:

• Must follow 3-day hospital stay requirement
• Only covers skilled care, not custodial care
• Limited to 100 days per benefit period
• Requires medical necessity and improvement potential
• No coverage for personal care or assistance with daily activities

Cost-sharing:

• Days 1-20: $0 copayment
• Days 21-100: $204.50 daily copayment (2026)
• Beyond 100 days: Full private pay responsibility

Texas Medicaid Long-term Care Coverage

What Texas Medicaid Covers:

• Nursing home care with no time limits
• Home and community-based services through waiver programs
• Personal care services and assistance with daily activities
• Adult day services and respite care
• Medical transportation to appointments
• Equipment and supplies for home care

Texas Medicaid Waiver Programs:

• Community Based Alternatives (CBA): For nursing home eligible seniors
• STAR+PLUS Home and Community-based Services: Managed care waiver services
• Deaf-Blind Multiple Disabilities (DBMD): Specialized services
• Texas Home Living (TxHmL): For individuals with intellectual disabilities

Medicaid Long-term Care Eligibility:

• Must meet nursing home level of care requirements
• Income limit: $2,829 monthly (2026)
• Asset limit: $2,000 individual
• Home and vehicle typically excluded from asset limits
• Spousal protection rules for married couples

Planning for Long-term Care Costs

The Reality for Texas Families:

• Average Texas nursing home cost: $4,500-7,000 monthly
• Home care services: $25-35 per hour
• Most private insurance doesn’t cover long-term care
• Medicare provides minimal long-term care coverage

Medicaid Planning Strategies:

• Asset protection through legal planning techniques
• Understanding look-back periods and transfer penalties
• Spousal impoverishment protections
• Proper timing of Medicaid applications

Dual Eligible Advantages:

• Medicare covers skilled services, Medicaid covers custodial care
• Seamless coordination between acute and long-term care
• Access to both nursing home and community-based services
• Protection from catastrophic long-term care costs

Prescription Drug Coverage: Medicare Part D vs. Texas Medicaid

Prescription drug coverage represents another area where Medicare and Medicaid differ significantly, with important implications for costs and access to medications.

Medicare Part D Prescription Coverage

Coverage Structure:

• Initial Coverage: Pay copayments or coinsurance after deductible
• Coverage Gap: Pay 25% of drug costs in the “donut hole”
• Catastrophic Coverage: Minimal costs after $8,000 out-of-pocket (2026)
• Plan Choices: Multiple private plans with different formularies

Cost Considerations:

• Monthly premiums: $15-100+ depending on plan
• Annual deductible: Up to $590 maximum
• Coverage gap creates significant mid-year costs
• Late enrollment penalties for delayed signup

For comprehensive information about Part D options, see our Medicare Part D guide for Texas.

Texas Medicaid Prescription Coverage

Coverage Benefits:

• Low copayments: Typically $1-3 for generic drugs, $3-5 for brand drugs
• No deductibles: Immediate coverage for covered medications
• No coverage gaps: Consistent coverage throughout the year
• Prior authorization: May be required for certain expensive medications

Formulary Considerations:

• Texas Medicaid maintains preferred drug list
• Generic drugs preferred when available
• Brand drugs covered when medically necessary
• Specialized medications available through prior authorization

Dual Eligible Prescription Benefits

Coordination Advantages:

• Medicare Part D provides primary coverage
• Medicaid covers Medicare Part D costs (premiums, deductibles, copayments)
• Access to Low-Income Subsidy (Extra Help) through Medicare
• Protection from coverage gaps and high out-of-pocket costs

Special Protections:

• Cannot be involuntarily disenrolled from Part D plans
• Access to formulary exceptions and appeals
• Protection from prior authorization for certain drug classes
• Transition fills when changing plans

Healthcare Provider Access: Network Differences

The choice between Medicare and Medicaid (or having both) significantly affects your access to healthcare providers in Texas.

Medicare Provider Network

Advantages:

• Any Medicare-accepting provider: Original Medicare works with any doctor who accepts Medicare
• Higher reimbursement rates: Providers receive better payment from Medicare
• Nationwide coverage: Works anywhere in the United States
• Specialist access: Generally easier access to specialists
• No referrals required: Direct access to specialists with Original Medicare

Medicare Advantage Considerations:

• Network restrictions may limit provider choices
• May require referrals for specialist care
• Generally better provider access than Medicaid networks
• Varying network quality between plans and regions

Texas Medicaid Provider Network

Challenges:

• Limited provider participation: Many providers don’t accept Medicaid
• Lower reimbursement rates: Providers receive less payment from Medicaid
• Managed care networks: Must use plan’s network providers
• Referral requirements: May need primary care physician referrals for specialists
• Wait times: May experience longer wait times for appointments

Advantages:

• Comprehensive care coordination: Managed care plans coordinate services
• Community health centers: Access to federally qualified health centers
• Specialized programs: Unique services for specific populations
• Care management: Additional support for complex medical needs

Dual Eligible Provider Benefits

Enhanced Access:

• Medicare payment rates encourage broader provider participation
• Medicaid covers costs that providers might otherwise bill patients
• Access to both Medicare and Medicaid provider networks
• Care coordination between different types of providers

Quality Considerations:

• D-SNPs often have specialized provider networks
• Providers familiar with dual eligible populations
• Integrated care teams addressing both medical and social needs
• Enhanced communication between providers

Applying for Medicare and Medicaid in Texas

Understanding how to apply for these programs and when to apply is crucial for obtaining coverage without gaps or penalties.

Medicare Application Process

Initial Enrollment Period:

• 7 months surrounding your 65th birthday
• 3 months before, birthday month, 3 months after
• Automatic enrollment if receiving Social Security

Application Methods:

• Online: Through Social Security Administration website
• Phone: Call Social Security at 1-800-772-1213
• In-person: Visit local Social Security office
• Automatic: If already receiving Social Security benefits

Required Information:

• Social Security number and birth certificate
• Employment history and income information
• Current health insurance information
• Banking information for premium payments

Texas Medicaid Application Process

Application Methods:

• Online: YourTexasBenefits.com
• Phone: 2-1-1 Texas helpline
• In-person: Local THHSC offices
• Healthcare facilities: Hospital presumptive eligibility programs

Required Documentation:

• Identity: Driver’s license or state ID
• Citizenship: Birth certificate or naturalization papers
• Income: Pay stubs, Social Security statements, pension information
• Assets: Bank statements, property records, vehicle titles
• Medical: Disability documentation if applicable

Processing Timeline:

• Applications processed within 45 days for aged/disabled
• Expedited processing for urgent medical needs
• Coverage can be retroactive up to 3 months
• Regular renewals required to maintain coverage

Dual Eligible Application Strategy

Coordinated Approach:

1. Apply for Medicare during your Initial Enrollment Period
2. Apply for Medicaid or Medicare Savings Programs through THHSC
3. Consider D-SNPs for integrated coverage
4. Get help from SHIP counselors for guidance

Timing Considerations:

• Don’t delay Medicare enrollment while waiting for Medicaid determination
• Medicare late enrollment penalties continue even if later approved for Medicaid
• Retroactive Medicaid coverage can help pay Medicare costs

Special Situations and Exceptions

Several special situations create unique considerations for Medicare and Medicaid coverage in Texas.

Working Past Age 65

Medicare Considerations:

• Can delay Part B enrollment if employer coverage is creditable
• Must enroll within 8 months of losing employer coverage
• Employer coverage may coordinate with Medicare as secondary payer

Medicaid Implications:

• Work income may exceed Medicaid eligibility limits
• May qualify for Medicaid working disabled programs
• Asset limits still apply regardless of work status

Moving to or from Texas

Medicare Portability:

• Medicare coverage works nationwide
• May qualify for Special Enrollment Period to change Medicare Advantage or Part D plans
• Medicare Supplement plans may have different rates in different states

Medicaid State Residency:

• Must establish Texas residency to qualify for Texas Medicaid
• Cannot have Medicaid in multiple states simultaneously
• Application required in new state of residence
• Coverage may be different between states

Immigration Status Considerations

Medicare Eligibility:

• Must be U.S. citizen or legal permanent resident for 5+ years
• Work history requirements still apply
• Limited coverage available for emergency services only

Texas Medicaid Options:

• Emergency Medicaid available regardless of immigration status
• Full Medicaid for qualified immigrants meeting residency requirements
• Children may qualify for CHIP regardless of parent’s immigration status

Frequently Asked Questions: Medicare vs. Medicaid in Texas

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

Yes, you can have both Medicare and Medicaid simultaneously if you meet the eligibility requirements for both programs. This is called being “dual eligible.”

How it works when you have both:

• Medicare pays first for services covered by both programs
• Medicaid pays Medicare costs including premiums, deductibles, and coinsurance
• Medicaid provides additional services that Medicare doesn’t cover
• You get more comprehensive coverage than either program alone

Who qualifies for both:

• Age 65+ or disabled AND have limited income and assets
• Income must be within Medicaid limits (around $943/month for individuals in 2026)
• Assets must be under $2,000 for individuals, $3,000 for couples
• Automatic Medicaid eligibility if receiving Supplemental Security Income (SSI)

What is the income limit to qualify for Medicaid in Texas?

Texas Medicaid income limits are very restrictive, especially for adults:

For Adults 65+ or Disabled:

• Individual: $943 monthly income limit
• Couple: $1,281 monthly income limit
• Asset limits: $2,000 individual, $3,000 couple

For Parents and Caretakers:

• Only 22% of Federal Poverty Level (about $334/month for individuals)
• This leaves many working parents without coverage options

For Children and Pregnant Women:

• Children: Up to 201% of Federal Poverty Level ($3,077/month)
• Pregnant women: Up to 185% of Federal Poverty Level ($2,832/month)

Important: Texas has not expanded Medicaid, so adults without children or disabilities have very limited coverage options regardless of income level.

Does Medicare cover long-term care costs in nursing homes?

Medicare provides very limited long-term care coverage:

What Medicare DOES cover:

• Skilled nursing facility care for up to 100 days per benefit period
• Must follow a qualifying 3-day hospital stay
• Only covers skilled medical care, not custodial care
• Days 1-20 are free, days 21-100 have $204.50 daily copayment (2026)

What Medicare does NOT cover:

• Custodial care (help with bathing, dressing, eating)
• Long-term nursing home stays beyond 100 days
• Assisted living facilities
• Personal care services at home

For comprehensive long-term care, you need:

• Medicaid (covers nursing home care indefinitely)
• Private long-term care insurance
• Personal savings and family support
• Veterans benefits if you’re a qualifying veteran

If I have Medicare, do I still need to apply for Medicaid?

It depends on your income and healthcare needs:

You should apply for Medicaid if:

• Your income is below $943/month (individual) or $1,281/month (couple)
• You need help paying Medicare premiums, deductibles, and coinsurance
• You need services Medicare doesn’t cover (dental, vision, long-term care)
• You’re struggling to afford prescription medications

Benefits of having both:

• No Medicare out-of-pocket costs - Medicaid pays your Medicare expenses
• Additional services like dental, vision, transportation
• Better prescription drug coverage with minimal copayments
• Long-term care coverage not available through Medicare

If your income is slightly above Medicaid limits, you may still qualify for Medicare Savings Programs that help pay Medicare costs.

How do I apply for both Medicare and Medicaid in Texas?

Apply for each program separately:

Medicare Application:

• Apply through Social Security Administration
• Online at ssa.gov, by phone at 1-800-772-1213, or at local Social Security office
• Apply during your Initial Enrollment Period (7 months around 65th birthday)

Texas Medicaid Application:

• Apply through Texas Health and Human Services Commission (THHSC)
• Online at YourTexasBenefits.com, by phone at 2-1-1, or at local THHSC office
• Can apply anytime if you meet eligibility requirements

Important timing:

• Don’t delay Medicare enrollment while waiting for Medicaid decision
• Medicare late enrollment penalties apply even if you later qualify for Medicaid
• Get help from Texas SHIP counselors: 1-800-252-9240

What’s the difference between Medicare Advantage and regular Medicaid managed care?

These are completely different types of programs:

Medicare Advantage:

• Replaces Original Medicare (Parts A and B)
• Private insurance companies approved by Medicare
• Usually includes prescription drug coverage
• May have additional benefits like dental and vision
• Available to all Medicare beneficiaries
• Network restrictions and referral requirements

Texas Medicaid Managed Care:

• Medicaid coverage delivered through private health plans
• For low-income individuals who qualify for Medicaid
• Includes comprehensive medical, dental, and behavioral health services
• Examples: STAR, STAR+PLUS, STAR Kids programs
• Must meet Medicaid income and asset requirements

If you’re dual eligible, you might have:

• Medicare Advantage plan for your Medicare benefits
• Medicaid managed care plan for additional Medicaid services
• OR a Dual Eligible Special Needs Plan (D-SNP) that coordinates both

Can Medicare patients see the same doctors as Medicaid patients?

It depends on the specific providers and your coverage type:

Original Medicare:

• Can see any doctor who accepts Medicare
• Higher Medicare reimbursement rates encourage broader provider participation
• No network restrictions or referral requirements

Texas Medicaid:

• Must use providers in your Medicaid plan’s network
• Lower reimbursement rates mean fewer providers accept Medicaid
• May need referrals from primary care physician

If you have both (dual eligible):

• Best provider access because Medicare payment rates are attractive to providers
• Medicaid covers the costs that providers might otherwise bill you
• Can access both Medicare and Medicaid provider networks

Medicare Advantage considerations:

• Network restrictions may limit choices
• Generally better provider access than Medicaid-only networks
• Provider participation varies by plan and region

How does prescription drug coverage work if I have both Medicare and Medicaid?

When you have both Medicare and Medicaid, prescription coverage is coordinated:

How it works:

• Medicare Part D provides primary coverage for prescriptions
• Medicaid pays your Medicare Part D costs (premiums, deductibles, copayments)
• You automatically qualify for Extra Help (Low-Income Subsidy) through Medicare
• Result: Minimal prescription costs ($4.50 generics, $11.20 brands in 2026)

Additional protections:

• No coverage gap (“donut hole”) problems
• Cannot be involuntarily disenrolled from Part D plans
• Special access to formulary exceptions
• Transition supplies when changing plans

If you only have Medicaid:

• Texas Medicaid covers prescriptions with small copayments ($1-5)
• Limited to Medicaid formulary and provider network
• May have prior authorization requirements

For detailed information about prescription coverage, see our complete Medicare Part D guide.

Getting Help Navigating Medicare and Medicaid in Texas

Understanding Medicare and Medicaid can be complex, especially when trying to coordinate benefits or determine eligibility for both programs. Professional assistance is available to help you navigate these systems.

Texas State Health Insurance Assistance Program (SHIP)

Free Services Available:

• Unbiased information about Medicare and Medicaid
• Help understanding dual eligible benefits and options
• Assistance with Medicare applications and appeals
• Guidance on Medicare Savings Programs
• Comparison of Medicare Supplement and Medicare Advantage options

How to Access SHIP Services:

• Statewide helpline: 1-800-252-9240
• Local SHIP offices throughout Texas
• Community education seminars
• Online resources through THHSC website

Texas Health and Human Services Commission (THHSC)

Medicaid-Related Services:

• Determine Medicaid eligibility
• Assist with Medicaid applications and renewals
• Provide information about Texas Medicaid programs
• Connect dual eligible individuals with appropriate services

Contact Information:

• 2-1-1 Texas: Dial 2-1-1 for benefits assistance
• Local THHSC offices throughout Texas
• YourTexasBenefits.com: Online portal for applications
• THHSC website: Educational resources and program information

Professional Medicare and Medicaid Assistance

Licensed Insurance Agents:

• Help compare Medicare Supplement and Medicare Advantage options
• Assist with Medicare Part D plan selection
• Provide ongoing service and annual reviews
• Specialize in dual eligible coverage options

Benefits Counselors:

• Help navigate both Medicare and Medicaid systems
• Assist with coordinating benefits between programs
• Help with applications and appeals processes
• Provide ongoing support for coverage changes

Contact Us for Expert Medicare and Medicaid Guidance

Navigating the differences between Medicare and Medicaid, understanding dual eligible benefits, and coordinating coverage between programs can be complex. Our team of specialists understands both Medicare and Texas Medicaid systems and can help you optimize your healthcare coverage.

Our Services Include:

• Eligibility determination for Medicare, Medicaid, and dual eligible programs
• Benefit coordination to maximize your coverage while minimizing costs
• Application assistance for both Medicare and Texas Medicaid programs
• Plan comparisons including Medicare Supplement, Medicare Advantage, and dual eligible special needs plans
• Appeals assistance when coverage is denied or benefits are insufficient

We Specialize in:

• Dual eligible coverage optimization
• Medicare Savings Program applications
• Long-term care planning with Medicare and Medicaid coordination
• Prescription drug coverage for dual eligible individuals
• Transitions between coverage types

Why Choose Our Texas Medicare and Medicaid Specialists:

• Deep understanding of both federal Medicare and Texas Medicaid systems
• Experience with THHSC processes and requirements
• Ongoing relationships with Medicare and Medicaid programs
• Personalized service focused on your unique situation
• No-cost consultations and ongoing support

Contact us today for your free Medicare and Medicaid consultation:

Phone: 1-800-MEDICARE-TX
Email: info@texasmedicareseniors.com
Online: Schedule a consultation through our website
Local Support: Available throughout Texas

Don’t navigate Medicare and Medicaid alone. Let our experienced team help you understand your options and optimize your healthcare coverage.

Conclusion: Making Informed Healthcare Coverage Decisions

Understanding the differences between Medicare and Medicaid in Texas is essential for making informed healthcare coverage decisions. While Medicare provides standardized federal benefits based primarily on age or disability, Medicaid offers comprehensive healthcare coverage for those with limited income and resources.

The most fortunate individuals are those who qualify for both programs, receiving the broad provider access and standardized benefits of Medicare while having their costs covered and gaps filled by Medicaid. This dual eligible status provides some of the most comprehensive healthcare coverage available.

Key takeaways for Texas residents:

• Medicare provides essential healthcare coverage for seniors and disabled individuals but has gaps and costs that can be significant
• Medicaid offers comprehensive coverage for those who qualify but has strict income and asset limits in Texas
• Dual eligible coverage combines the best of both programs for those who qualify
• Texas has not expanded Medicaid, leaving coverage gaps for many low-income adults
• Professional assistance is available to help navigate both systems

Whether you’re approaching Medicare eligibility, facing financial hardship, or trying to coordinate benefits between programs, understanding these systems helps you make the best decisions for your healthcare needs and budget.

For comprehensive information about all your Medicare options in Texas, explore our other detailed guides:

• Complete Guide to Medicare in Texas
• Best Medicare Advantage Plans in Texas
• Medicare Enrollment in Texas: Complete Guide

The right healthcare coverage provides security, peace of mind, and access to the care you need. Take the time to understand your options, seek professional assistance when needed, and make informed decisions about your Medicare and Medicaid coverage.