Medicaid for Seniors: A Complete Guide to Coverage and Benefits (2025)

Most people think Medicaid is only for nursing homes. But Medicaid is actually one of the most important healthcare programs for seniors with limited income or assets—covering hospital care, doctor visits, prescriptions, home care, and in most states some dental and vision coverage. And for long-term care, Medicaid—not Medicare—is the primary payer in America.

For seniors who qualify, Medicaid can function as full health insurance, wrap around Medicare, or fund long-term care at home or in a facility. This guide explains exactly what Medicaid covers, how eligibility works, how New Jersey handles benefits, and how rules differ across states.

Medicare vs. Medicaid: The Basics

Medicare

Federal program for people 65+ or disabled
Not based on income or assets
Covers hospital (Part A) and medical care (Part B)
Requires premiums, deductibles, and coinsurance
DOES NOT cover long-term custodial care
DOES NOT cover most dental, vision, or hearing care

Medicaid

Joint federal/state program based on financial need
Covers comprehensive health services
DOES cover long-term custodial care
Typically very low or no cost-sharing
Rules depend heavily on your state

Dual Eligible (Medicare + Medicaid)

If you qualify for both:

Medicare pays first
Medicaid pays Medicare deductibles, copays, coinsurance
Medicaid covers extra services Medicare doesn't (like long-term care, sometimes dental/vision)
Medicaid manages your Medicare cost-sharing based on your level of Medicaid

What Medicaid Covers for Seniors

Coverage varies by state, but the following services are universally required or commonly included.

1. Hospital Care

Inpatient:

Unlimited hospital days (unlike Medicare)
Surgery, room/board, medications, nursing care
Lab tests, imaging, supplies

Outpatient:

ER visits
Outpatient surgery
Chemotherapy, dialysis, radiation
Observation stays

Cost to you: Usually $0 or small nominal copays ($1–$3 in some states)

2. Doctor Visits & Specialist Care

Primary care visits
Specialists (cardiology, oncology, endocrinology, etc.)
Chronic disease management
Vaccinations
Preventive screenings

Cost: $0 to $3 per visit in most states

3. Prescription Drugs

All states cover prescription drugs for Medicaid beneficiaries.

Brand and generic medications
Chronic and acute care drugs
OTC medications with a prescription (varies by state)

Cost: Typical copays are $0–$3. Medicaid does not have a donut hole.

4. Preventive Care

All at $0 cost:

Mammograms, colonoscopies, lung cancer screening
Diabetes screening
Cardiovascular screening
Vaccines (flu, pneumonia, shingles, COVID-19)
Tobacco cessation
Obesity counseling

5. Medical Equipment & Supplies

Wheelchairs, walkers
Hospital beds
Nebulizers, oxygen
CPAP machines
Diabetic supplies
Ostomy supplies
Wound care supplies
Incontinence products (varies by state)

Cost: $0 in most states

6. Mental Health & Substance Use Services

Psychiatric care
Therapy and counseling
Inpatient psychiatric stays
Intensive outpatient
Medication-assisted treatment (Suboxone, methadone)

Cost: $0 or nominal copays

7. Rehabilitation & Therapy

Physical therapy
Occupational therapy
Speech therapy
Pulmonary and cardiac rehab

Cost: Typically free or low copay

8. Home Health Services

If medically necessary:

Skilled nursing at home
Home health aides
Physical, occupational, and speech therapy
Medical social services

Cost: $0

9. Emergency & Urgent Care

ER services
Ambulance transportation
Urgent care centers

Cost: Usually free or small copay

Optional Services (Vary by State)

Dental Care

States vary widely:

Comprehensive dental states: CA, CT, MA, NY, VT and others

Limited dental (emergency only): Many states, including New Jersey

No adult dental: A handful of states

Comprehensive states may include:

Cleanings & exams
X-rays
Fillings
Extractions
Root canals
Dentures

Vision Care

Varies by state; commonly includes:

Eye exams
Glasses (frequency varies)
Treatment for glaucoma, cataracts, diabetic eye disease

Hearing

Some states cover:

Hearing exams
Hearing aids (limits vary)
Batteries/repairs

Other states cover exams only.

Podiatry

Some states cover diabetic and medically necessary foot care
Others limit to specific conditions

Medicaid & Long-Term Care (Most Important for Seniors)

This is where Medicaid becomes essential — Medicare does not cover custodial long-term care.

1. Nursing Home Medicaid

Covers:

24/7 nursing care
Room and board
Medications
Therapy services
Activities
Medical supplies

Cost:

You contribute most of your monthly income
You keep a small personal needs allowance ($30–$200 depending on state)
Your home is exempt while you live in it, but may be subject to estate recovery later

2. Home & Community-Based Services (HCBS)

Allows you to stay at home instead of entering a nursing home.

May include:

Personal care (bathing, dressing, toileting)
Meal prep, housekeeping
Adult day care
Respite
Transportation
Home modifications (ramps, grab bars)
Medical alert systems

HCBS availability varies widely. Some states have long waitlists.

3. Assisted Living via Medicaid

Varies widely:

Some states cover assisted living through waivers
Some do not
Coverage usually includes personal care but not room and board

Medicaid in New Jersey: What's Covered (2025)

New Jersey's Medicaid program is called NJ FamilyCare. For seniors, the program is Aged, Blind, Disabled (ABD) or MLTSS for long-term care.

Core Healthcare Coverage

New Jersey covers:

Doctor visits
Specialists
Hospital care
ER visits
Prescription drugs
Mental health care
Lab & imaging
Home health

All through one of NJ's Medicaid Managed Care Organizations (MCOs):

Horizon NJ Health
UnitedHealthcare Community Plan
WellCare of NJ
AmeriHealth Caritas NJ

Dental (NJ)

Adults: Emergency-only (pain relief, extractions)
Children: Full dental (EPSDT)

Vision (NJ)

Adults:

Exams covered
Glasses every 2 years

Hearing (NJ)

Exams covered
Limited hearing aid coverage for adults
Full coverage for children

Long-Term Care in NJ

1. Nursing Home Medicaid

2025 limits:

Income: $2,912/month
Assets: $2,000
Spousal asset allowance: Up to $154,140 (2025)

2. MLTSS (Home & Community-Based Services)

Includes:

Personal care
Adult day care
Home modifications
Assisted living services

Same income/asset rules as nursing home Medicaid.

3. Personal Preference Program (PPP)

A self-directed option:

You receive a budget
You can hire caregivers — including certain family members
You manage your care plan
Must qualify for MLTSS

NJ Pharmacy Assistance Programs (Separate from Medicaid)

PAAD (Pharmaceutical Assistance to the Aged & Disabled)

2025–26 limits:

Income: $43,735 individual / $49,898 couple
Assets: No limit
Pays Part D premiums & reduces drug costs

Senior Gold

For slightly higher incomes:

Acts as a wraparound to Part D
Reduced copays after ~$2,000 out-of-pocket

How Medicaid Varies by State

Mandatory in All States

Hospital services
Physician services
Lab/X-ray
Nursing home
Home health
Family planning
EPSDT (children)

Optional (State-Dependent)

Adult dental
Adult vision
Hearing aids
Chiropractic
Podiatry
Personal care services
HCBS waivers
Prescription drug coverage (formularies differ)
DME rules ("rent vs buy")

Financial Eligibility for Seniors (2025)

ABD Medicaid (Basic Medicaid)

Typical limits:

Income: ~$1,215–$1,600/month (varies by state)
Assets: $2,000

Nursing Home / HCBS

Most states use:

Income: $2,912/month
Assets: $2,000

Spousal Protections

Community spouse may keep up to $154,140 in assets (2025 CSRA)
May also receive a protected income allowance

Assets That Count vs Don't Count

Countable:

Savings/checking
Stocks, bonds
CDs
Second vehicles
Investment property

Not Counted:

Primary residence (up to equity cap)
One car
Personal belongings
Household goods
Wedding/engagement rings
Burial plots
Small burial funds

Medicare + Medicaid Working Together

For dual-eligible seniors:

Medicare pays first. Medicaid pays second.

Medicaid may pay:

Medicare Part B premium
Medicare deductibles
Coinsurance/copays
Services Medicare doesn't cover (dental, vision, transport, long-term care)

Medicare Savings Programs (MSPs)

If you don't qualify for full Medicaid, you might qualify for MSPs:

QMB – pays Part A/B premiums, deductibles, coinsurance
SLMB – pays Part B premium
QI – pays Part B premium (first-come, first-served)

QMB includes balance billing protection — providers cannot bill you for Medicare cost-sharing.

Extra Help (2025 Rules)

If you qualify for QMB, SLMB, or QI:

No Part D premium
No deductible
No coinsurance
No donut hole
You pay $0 for all covered prescriptions (2025 reform)

Common Medicaid Questions

Will Medicaid take my home?

Not while you're alive
Estate recovery may apply after death

Can I give assets to qualify?

Not safely—5-year look-back applies

Do I need to switch doctors?

Maybe — depends on your Medicaid MCO network

Can I have Medicaid and Medicare Advantage?

Yes — often through D-SNP plans

What if my income is slightly too high?

Options:

Medicaid spend-down (some states)
Qualified Income Trust (QIT/Miller Trust)

Getting Help

Medicaid is complicated. Seniors often need guidance from:

Patient advocates
Geriatric care managers
Medicaid planners
Elder law attorneys

You Don't Have to Navigate Medicaid Alone

Medicaid can be life-changing — but the rules are complex and mistakes can delay or block eligibility. Whether you live in Ocean County, Monmouth County, Central New Jersey, or anywhere in the U.S., getting the right help early makes the process much easier.

At SageAlly, we:

Explain Medicaid rules in your state
Determine which programs you may qualify for
Help you assemble required documents
Connect you with Medicaid planners and elder law attorneys
Navigate long-term care programs like MLTSS
Coordinate with Medicare benefits

You deserve healthcare that works — and guidance that makes the system easier to manage.