medicaid/florida/medicare-vs-medicaid

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By Brevy Care Team

These two programs sound nearly identical. They are completely different.

Medicare is federal health insurance based on age (65+) or qualifying disability. It is not income-based, anyone who paid into Social Security long enough qualifies, regardless of how much they earn.

Florida Medicaid is a joint federal-state program run by Florida's Agency for Health Care Administration (AHCA) for people with limited income and assets. The income test is real and strict, and Florida is a non-expansion state, which means working-age adults without children rarely qualify regardless of income, but seniors, people with disabilities, and those needing long-term care often do.

You can have both. Many Floridians are dual-eligible, qualifying for Medicare and Florida Medicaid at the same time. Even if you don't qualify for full Medicaid, Florida runs three Medicare Savings Programs that can pay your Medicare premiums and copays. This guide walks through exactly how the two programs differ, what each pays for in 2026, and how they fit together when you have both. {{/component}}

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Key Takeaways

• Medicare is federal and based on age (65+) or disability, no income test. Standard Part B premium is $202.90/month in 2026 (up from $185 in 2025); Part A is premium-free for most beneficiaries with 40+ quarters of work history.
• Florida Medicaid is state-administered through the Statewide Medicaid Managed Care (SMMC) program, strict income and asset limits, run through 8 active SMMC 3.0 plans across 9 lettered regions.
• Florida is a non-expansion state. Working-age adults under 65 without dependent children are generally ineligible for Medicaid regardless of income. The non-expansion gap is one of the most consequential coverage facts in Florida health policy.
• You can have both Medicare and Medicaid. A significant share of Florida's seniors are dual-eligible. Medicare pays first for medical care; Medicaid picks up cost-sharing and adds benefits Medicare doesn't cover (LTC, dental, transportation, OTC).
• Medicare does NOT cover long-term custodial care, only up to 100 days of skilled nursing facility care after a qualifying hospital stay. The Florida SMMC LTC waiver is the LTC pathway.
• Three Medicare Savings Programs in Florida help pay Medicare costs even if you don't qualify for full Medicaid: QMB (premiums + all cost-sharing), SLMB (Part B premium), and QI (Part B premium). 2026 income limits up to ~$1,660/month individual / ~$2,239/month couple for QI; resource limits $9,090/$13,630. {{/component}}

The 30-second answer

If a Floridian has worked enough quarters under Social Security and is 65 or older, they get Medicare. Period. Income doesn't matter, asset levels don't matter, and Florida residency doesn't matter, Medicare is portable nationally.

If that same Floridian also has limited income and assets, they may additionally qualify for Florida Medicaid. The income tests are strict; the asset tests are real but have meaningful exemptions (the homestead and one car are typically not counted). The two programs are not alternatives, they layer on top of each other for people who qualify for both.

The single most consequential mistake families make: assuming "Mom has Medicare, so we don't need to look at Medicaid." Wrong. Medicare alone has gaps, it doesn't cover long-term custodial care, has limited dental and vision benefits, and leaves seniors with deductibles and copays that can run into thousands of dollars a year. Florida Medicaid fills those gaps for people who qualify, and the Medicare Savings Programs help with Medicare costs even for those who don't qualify for full Medicaid.

What Medicare is and what it covers

Medicare is a federal health insurance program enacted in 1965 and administered by the Centers for Medicare and Medicaid Services (CMS). Eligibility is based on age or disability, not income.

Who qualifies

• People age 65 or older who are U.S. citizens or have been lawful permanent residents for at least five years
• People under 65 with certain disabilities (after 24 months of receiving Social Security Disability Insurance)
• People of any age with End-Stage Renal Disease (ESRD)
• People of any age with ALS (Lou Gehrig's disease, qualifies immediately on SSDI approval)

The four parts

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What Medicare does NOT cover (and where Florida seniors get tripped up)

• Long-term custodial care in a nursing home, assisted living facility, or at home, Medicare's "skilled nursing facility" benefit covers up to 100 days only after a qualifying 3-day inpatient hospital stay, and only for skilled care needs. Once the rehab is done, Medicare stops paying.
• Most dental, vision, and hearing services, original Medicare covers very little routine dental, vision, or hearing care. Some Medicare Advantage plans bundle these in.
• Hearing aids, original Medicare doesn't cover them at all. Some MA plans do.
• Cosmetic surgery, most chiropractic services, acupuncture (limited), most foot care

Medicare's 2026 cost numbers in detail

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• Part B premium: $202.90/month (standard); higher for higher-income beneficiaries via IRMAA surcharge (single $109K+ / joint $218K+ triggers IRMAA, scaling up to $689.90/month at the top tier)
• Part B deductible: $283/year
• Part B coinsurance: 20% of Medicare-approved amount after deductible
• Part A inpatient deductible: $1,736 per benefit period (each benefit period starts after 60 days out of hospital/SNF)
• Part A inpatient coinsurance: $0 days 1-60, $434/day days 61-90, $868/day for lifetime reserve days
• Part A SNF coinsurance: $0 days 1-20, $217/day days 21-100, full cost beyond day 100
• Part D average plan premium: $46.50/month
• Extra Help (Part D Low-Income Subsidy) resource limits: $9,950 individual / $14,910 couple {{/component}}

What Florida Medicaid is and what it covers

Florida Medicaid is the state's joint federal-state Medicaid program, operated by AHCA through the Statewide Medicaid Managed Care (SMMC) program. Eligibility is income- and asset-based and depends on which of six pathways the applicant fits, see /medicaid/florida/eligibility-income-limits for the full eligibility map.

Who qualifies in Florida

The reality of Florida Medicaid eligibility for adults:

• Children, pregnant women, and parents at very low income, under MAGI Medicaid; income limits are tight
• Seniors 65+ with limited income and assets, under MEDS-AD or LTC pathway
• Adults with disabilities receiving SSI, automatic via §1634 (Florida is a §1634 state)
• Medicare beneficiaries with limited income, under one of three Medicare Savings Programs

The Florida coverage gap: Florida has not expanded Medicaid under the Affordable Care Act, which means non-disabled, non-elderly adults without dependent children are generally ineligible regardless of income. A substantial number of Floridians fall into the coverage gap, earning too much for Medicaid and too little for ACA Marketplace subsidies.

What Florida Medicaid covers (that Medicare doesn't)

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For a senior on Medicare who needs help bathing, dressing, or moving around at home, Medicare does not pay. Florida Medicaid LTC does. This is the single most important reason why families need to understand Medicaid even when their parent is on Medicare.

The side-by-side comparison

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Can you have both? (Yes, and you should know what that means)

Many Floridians have both Medicare and Florida Medicaid, making them "dual-eligible." This is one of the most advantageous coverage positions in U.S. health care because the two programs cover each other's gaps almost perfectly.

There are two general types of dual eligibility:

Full duals

The senior qualifies for full Florida Medicaid (typically through MEDS-AD, the LTC waiver, or §1634 SSI-linked) PLUS Medicare. Full duals get:

• All Medicare benefits (medical, hospital, prescription drugs)
• All Florida Medicaid benefits, including long-term care, transportation, dental (limited), and OTC items
• Medicare premiums paid by Medicaid (Part A and Part B)
• Medicare cost-sharing (deductibles, copays, coinsurance) paid by Medicaid
• Automatic Extra Help / Low-Income Subsidy for prescription drugs

Partial duals (Medicare Savings Program enrollees)

The senior has Medicare and qualifies for one of the three Florida Medicare Savings Programs based on slightly higher income. Partial duals get specific Medicare cost help but not the full Medicaid benefit package.

Florida Medicare Savings Programs (MSPs)

Florida runs three Medicare Savings Programs through DCF. They are individually-administered eligibility categories under the Medicaid umbrella but specifically scoped to help with Medicare costs. Even seniors who don't qualify for full Florida Medicaid often qualify for one of these.

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QMB is the most generous, it pays everything Medicare doesn't (premiums + all cost-sharing) and effectively eliminates Medicare out-of-pocket costs. SLMB and QI pay only the Part B premium ($202.90/month in 2026), which is still meaningful, that's $2,434.80/year of pure premium savings.

The October 2025 family-size rule expansion

Florida expanded MSP eligibility in October 2025. The state now includes "any blood, marriage, or adoption relative living with and dependent on the applicant" in the household-size determination, which has the effect of raising the applicable income limit for many applicants. If you were denied an MSP before October 2025, re-apply, the rule change may have made you eligible.

How to apply for an MSP in Florida

Apply through DCF's ACCESS Florida portal at myaccess.myflfamilies.com or by phone at (850) 300-4323. The MSP application is technically the same form as the full Medicaid application; DCF determines which pathway you qualify for based on your income and assets. There's no separate MSP form.

If you're already receiving Social Security and qualify for an MSP, the Part B premium that would otherwise be deducted from your Social Security check is paid by Medicaid instead, meaning your monthly check goes UP by $202.90 (in 2026) once the MSP enrollment is processed.

How Medicare and Florida Medicaid coordinate when you have both

For a dual-eligible Floridian, the basic rule is simple: Medicare pays first, Medicaid pays second. The technical term is "Medicare is the primary payer."

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Doctor visits and hospital care

You go to the doctor or hospital. Medicare pays the standard 80% (after deductible). Florida Medicaid pays the remaining 20% coinsurance and the deductible. You owe nothing.

Prescription drugs

You get drugs through your Medicare Part D plan (or your Medicare Advantage plan's drug benefit). The Part D Low-Income Subsidy (Extra Help) is automatic for full duals and dramatically reduces copays, often to $0 for generics and a few dollars for brand-name drugs.

Skilled nursing facility (the Medicare 100-day benefit)

After a qualifying 3-day inpatient hospital stay, Medicare covers up to 100 days of SNF care. For days 1-20, Medicare pays everything. For days 21-100, Medicare pays most of the cost but the patient owes a daily coinsurance ($217/day in 2026). Florida Medicaid pays that coinsurance for duals.

After day 100, Medicare stops. If the patient still needs skilled care, the SMMC LTC waiver picks up, assuming the patient is enrolled and meets level-of-care requirements.

Long-term custodial care

Medicare doesn't pay. Florida Medicaid LTC does, but only after the financial and clinical eligibility process completes (see /medicaid/florida/how-to-apply).

Durable medical equipment

Medicare DME pays for many medically necessary items (wheelchairs, oxygen, hospital beds). Florida Medicaid covers items Medicare doesn't, plus picks up any Medicare cost-sharing.

Transportation

Medicare doesn't pay for non-emergency medical transportation. Florida Medicaid does, most SMMC plans include free rides to medical appointments, and case managers can arrange them. {{/component}}

Dual-eligible Special Needs Plans (D-SNPs) in Florida

A D-SNP is a special type of Medicare Advantage plan designed exclusively for dual-eligibles. D-SNPs combine Medicare and Medicaid benefits into a single plan, with one ID card, one provider network, and (usually) coordinated case management.

In Florida, the major Medicaid LTC plans operate aligned D-SNPs through their parent companies' Medicare divisions:

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Florida Community Care (FCC) is the major exception, it's a Medicaid-only plan operated by Independent Living Systems and does not have an aligned D-SNP. Members on FCC for Medicaid LTC must enroll in a separately-chosen Medicare plan (original Medicare + Medigap, or any Medicare Advantage plan they want).

Should you enroll in a D-SNP?

The case for: a single plan, coordinated case management, often $0 premium (because Medicaid pays your Part B premium), and frequently extra benefits like dental, vision, hearing aids, or OTC allowances.

The case against: D-SNPs limit you to the plan's network on both Medicare and Medicaid sides. If you want to keep an out-of-network specialist, a D-SNP may not work. Original Medicare has the broadest provider network in U.S. healthcare; D-SNPs trade some of that breadth for coordination.

For most low-asset dual-eligibles in Florida, an aligned D-SNP is the right answer because the coordination value is high and the network limitations are usually acceptable. For dual-eligibles with strong existing provider relationships outside the SMMC plan's network, original Medicare + Medigap-equivalent (which Medicaid often functions as for full duals) may be better.

Who pays for long-term care in Florida, the most-confused question

The single most-asked question by Florida families: "Will Medicare pay for the nursing home?"

The honest answer is: for short-term rehab after a hospital stay, partly. For long-term custodial care, no, never.

{{component: callout, type: warning}} Medicare's 100-day SNF benefit is the most-misunderstood Medicare benefit. It only kicks in after a qualifying 3-day inpatient hospital admission, only covers SKILLED care needs (not custodial care), and ends as soon as the patient stops needing skilled rehab, which is almost always before day 100. Many Medicare SNF stays end at day 20-30 because the patient stabilizes and Medicare stops paying. {{/component}}

For long-term custodial care, the everyday help with bathing, dressing, eating, transferring, toileting, and supervision that an aging parent typically needs, the U.S. health care system has three payers:

1. Out of pocket, the senior pays private-pay rates from savings until depleted.
2. Long-term care insurance, if purchased before the senior needed care, can pay a significant portion of LTC costs.
3. Florida Medicaid LTC, the SMMC LTC waiver and Institutional Care Program (ICP) cover nursing home, ALF, and home-and-community-based services for eligible Floridians.

For most Florida families, the realistic LTC funding picture is: out-of-pocket spend-down for some period, then Medicaid LTC. The work of LTC planning is making the spend-down period as short as possible while keeping the spouse/family financially stable. See /medicaid/florida/eligibility-income-limits and /medicaid/florida/estate-recovery for the planning playbook.

How to apply for each

Medicare

For most people, Medicare enrollment is automatic when you turn 65 if you're already receiving Social Security. Otherwise:

• Initial Enrollment Period (IEP): 7 months around your 65th birthday (3 months before, your birthday month, 3 months after)
• Apply at: ssa.gov/medicare or 1-800-772-1213 or in person at any Social Security office (Florida has 100+)
• Late enrollment penalties: 10% per year for Part B (lifetime); 1% per uncovered month for Part D
• Medicare Annual Open Enrollment: October 15 – December 7 each year (changes Medicare Advantage and Part D for the following year)

Florida Medicaid

Apply through DCF's ACCESS Florida system:

• Online: myaccess.myflfamilies.com (preferred)
• Phone: (850) 300-4323
• In person: Any DCF Customer Service Center, AAA, or community partner
• For LTC specifically: also call Elder Helpline at 1-800-963-5337 to start the AAA/CARES clinical clock

For a step-by-step walkthrough of the Florida Medicaid application by pathway, see /medicaid/florida/how-to-apply.

Frequently asked questions

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Is Medicare and Medicaid the same thing?

No, they are completely separate programs. Medicare is federal age/disability-based health insurance. Florida Medicaid is a federal-state income/asset-based program. You can have one, the other, or both. The branding similarity is unfortunate; the programs are not.

Why do people say "Medicare doesn't pay for nursing homes" when Medicare has a SNF benefit?

Medicare covers skilled care after a qualifying 3-day hospital stay, for up to 100 days. It does NOT cover custodial care (help with daily living activities), even when delivered in a nursing home, at any point. Most long-term nursing home stays are custodial, not skilled, which is why Medicare almost never pays.

Can I get Medicare if I'm under 65?

Yes, if you've been receiving Social Security Disability Insurance (SSDI) for 24 months, OR you have ALS (Lou Gehrig's disease, immediate eligibility), OR you have End-Stage Renal Disease (eligibility tied to dialysis or transplant).

How does Medicaid know I have Medicare?

DCF asks during the application. They also have data-sharing with SSA and CMS that flags Medicare enrollment. If you have Medicare, list it on the application, it actually helps your Medicaid eligibility because Medicare is the primary payer and reduces what Medicaid has to cover.

Will Medicaid pay my Medicare premiums?

Yes for full duals, Florida Medicaid pays Part A and Part B premiums for dual-eligibles. Yes for QMB partial duals, QMB covers premiums and all cost-sharing. SLMB and QI pay only the Part B premium ($202.90/month in 2026).

Can I have a Medicare Advantage plan AND Florida Medicaid?

Yes. The cleanest setup for dual-eligibles is a D-SNP, a Medicare Advantage plan designed for duals, often aligned with the same parent company as your Florida Medicaid LTC plan. Humana, Aetna, UHC, Sunshine/Wellcare, and Simply/Wellpoint all offer FL D-SNPs.

Will Medicaid affect my Social Security?

No, Medicaid eligibility doesn't affect your Social Security retirement or disability benefits. Your Social Security IS counted as income for Medicaid eligibility (which is why income-cap states like Florida often require a Qualified Income Trust for higher Social Security recipients), but receiving Medicaid doesn't reduce Social Security.

What if my income is too high for Medicaid but too low to afford Medicare cost-sharing?

That's exactly what the Medicare Savings Programs are for. QMB, SLMB, and QI cover Medicare premiums (and for QMB, all cost-sharing) for Medicare beneficiaries with incomes too high for full Medicaid but below the MSP thresholds. Apply through DCF's ACCESS Florida.

Does the Affordable Care Act help?

In a Medicaid-expansion state, yes, adults under 65 with incomes up to 138% of FPL would qualify for Medicaid. Florida is a non-expansion state, so the ACA's main effect is the Marketplace subsidies for incomes between 100% and 400% FPL. Working-age adults below 100% FPL in Florida fall into the "coverage gap", earning too little for Marketplace subsidies and ineligible for Medicaid because Florida didn't expand. Roughly 415,000 Floridians are in this gap.

Should I get Medigap or Medicare Advantage?

This question is its own deep rabbit hole. The short version for Florida: if you're a dual-eligible, you almost certainly want a D-SNP rather than Medigap (because Medicaid functions as supplemental coverage and Medigap doesn't coordinate with Medicaid). If you're Medicare-only and value provider flexibility, Medigap + Original Medicare. If you value extra benefits and a coordinated plan and don't mind the network, Medicare Advantage. Talk to a Florida SHINE counselor (free) at 1-800-963-5337 (the same Elder Helpline number).

Where do I get free help understanding Medicare in Florida?

Florida SHINE (Serving Health Insurance Needs of Elders) is the state's free Medicare counseling program, administered by DOEA. SHINE counselors are trained volunteers who help with plan selection, appeals, and Extra Help applications. Call 1-800-963-5337 (Elder Helpline) or visit floridashine.org.

What if I have employer or union retiree coverage?

Coordination depends on the employer's group size and your retiree status. For most retirees over 65 with retiree coverage, Medicare is primary and the retiree plan is secondary. Talk to the employer's benefits department before making decisions about Medicare Part B enrollment, late enrollment penalties for Part B are lifetime and meaningful. {{/component}}

Bottom line

Medicare and Florida Medicaid are not alternatives, they're complementary programs that together fill most gaps in U.S. health coverage for older Floridians. The single biggest mistake families make is assuming "Mom has Medicare, so we're set." That assumption misses the Medicare cost-sharing problem (where MSPs help), the long-term-care problem (where Medicaid LTC is the only U.S. payer at scale), and the supplemental-benefits problem (where dual eligibility unlocks dental, transportation, OTC allowances, and other valuable extras).

If you're approaching 65 in Florida, talk to SSA about Medicare and (separately) screen for Medicaid/MSP eligibility through DCF. If you're a family caregiver for a Medicare beneficiary, run a Medicaid eligibility check at any indication that LTC may be needed in the next 5 years, because the 60-month look-back rewards early planning.

Free help is available. Florida SHINE for Medicare. DCF ACCESS Florida for Medicaid. Elder Helpline 1-800-963-5337 for both.

Internal references:

• Florida Medicaid Programs Overview
• Florida Medicaid Eligibility & Income Limits 2026
• How to Apply for Florida Medicaid
• Florida Long-Term Care Waiver Guide
• Florida Medicaid Managed Care Plans
• Florida Medicaid Estate Recovery
• How to Get Paid as a Family Caregiver in Florida
• Glossary: Medicare Savings Programs
• Glossary: D-SNP
• Glossary: Dual Eligible
• Glossary: Extra Help (LIS)
• Glossary: Medigap