Medicare and Medicaid in Florida: Eligibility, Costs, and Dual Coverage

Medicare and Medicaid in Florida are two separate programs that people often confuse because both help pay for health care. Medicare is a federal program you qualify for based on age (65 and up) or certain disabilities, regardless of income. Florida Medicaid is a state-administered program for low-income residents, with strict eligibility categories and, for older adults and long-term care applicants, tight limits on both income and assets. Because Florida has not expanded Medicaid under the Affordable Care Act, many low-income working-age adults without children or a disability fall into a coverage gap: too much income for Medicaid, too little for marketplace subsidies. Some people qualify for both programs at once and are known as dual eligibles.

Who Qualifies for Medicare

You become eligible for Medicare at 65, regardless of income or health status. Younger people qualify after receiving Social Security Disability Insurance benefits for 24 consecutive months. People diagnosed with End-Stage Renal Disease or ALS can get Medicare without waiting the full 24 months.¹ Enrollment for Parts A and B runs through the Social Security Administration, online or in person.²

Your Initial Enrollment Period is a seven-month window: three months before your 65th birthday month, the birthday month itself, and three months after. Miss it and you’ll wait for the General Enrollment Period (January 1 through March 31), with coverage starting July 1 and a late enrollment penalty attached. The Part B penalty adds 10% to your monthly premium for every full 12-month period you could have enrolled but didn’t, and that surcharge stays on your premium for life.³

If you delayed Part B because you had employer-sponsored group health coverage, a Special Enrollment Period lets you sign up without penalty. That window lasts eight months starting when your employment or group coverage ends, whichever comes first.²

What Medicare Costs in 2026

Part A (hospital insurance) is premium-free for most people who paid Medicare taxes for at least 10 years. The inpatient hospital deductible is $1,736 per benefit period in 2026. Skilled nursing facility stays are free for days 1 through 20, cost $217 per day for days 21 through 100, and then you pay in full.⁴

Part B (medical insurance) has a standard 2026 premium of $202.90 per month, higher for upper-income enrollees. After the $283 annual deductible, you generally pay 20% of the Medicare-approved amount for covered services, and Original Medicare has no annual cap on that share.⁴

Part C (Medicare Advantage) plans, offered by private insurers, bundle Parts A and B, usually add drug coverage, and often include dental, vision, and hearing. Unlike Original Medicare, every Advantage plan caps annual out-of-pocket spending. Part D covers prescriptions, either as a standalone plan alongside Original Medicare or built into most Advantage plans.⁴

Medigap in Florida

Original Medicare leaves gaps, especially the uncapped 20% Part B coinsurance. Medigap policies, sold by private insurers, cover some or all of those out-of-pocket costs. Federal law gives you a one-time, six-month Medigap Open Enrollment Period starting the first month you have both Part B and are 65 or older. During that window, insurers cannot turn you down or charge more because of health conditions.⁵

After that window closes, insurers in most cases can use medical underwriting to deny coverage or raise premiums. Florida adds a state-level protection: an annual open enrollment period around your birthday during which you can switch Medigap plans without medical underwriting. If you plan to stay with Original Medicare rather than an Advantage plan, buying Medigap during your initial six months is the safest move because your health can’t be held against you.

Who Qualifies for Florida Medicaid

Florida’s Medicaid program is administered by the Agency for Health Care Administration, with eligibility handled by the Department of Children and Families.⁶ Which eligibility group you fall into matters, because the rules split sharply between two tracks.

Children, Pregnant Women, and Parents (MAGI Rules)

For children, pregnant women, and parents or caretaker relatives, Florida uses Modified Adjusted Gross Income rules. These look only at income relative to the federal poverty level, with no asset test.⁷ The 2026 FPL is $15,960 per year ($1,330 per month) for an individual and $21,640 for a family of two.⁸ Children qualify at higher income thresholds than adults.

Because Florida has not expanded Medicaid, working-age adults without a disability generally must be caring for a child or dependent family member to qualify, and income limits for parents are roughly 26% of FPL (about $592 per month for a family of three). Childless adults without a qualifying disability typically don’t qualify at all, regardless of how little they earn.

Aged, Blind, Disabled, and Long-Term Care (Non-MAGI Rules)

People 65 and older, those who are blind or disabled, and anyone seeking nursing home or long-term care follow Non-MAGI rules, which impose limits on both income and countable assets.⁷

For long-term care applicants, the gross monthly income limit is 300% of the federal SSI benefit. In 2026, SSI for an individual is $994 per month, which puts the income cap at $2,982.⁹ Countable assets for an individual are limited to $2,000. Exempt from the count: your primary home (up to an equity limit), one vehicle, personal belongings, and irrevocable burial contracts.

When a married person applies for nursing home Medicaid, the non-applicant spouse can keep a Community Spouse Resource Allowance of up to $162,660 in 2026. If the applicant’s income exceeds the $2,982 cap, a Qualified Income Trust (sometimes called a Miller Trust) lets excess income be deposited each month so the applicant can still qualify.

The Five-Year Look-Back

When you apply for long-term care Medicaid, Florida reviews all asset transfers you made during the 60 months before your application date. Gifts or below-market sales in that window trigger a penalty period during which you’re ineligible for benefits.¹⁰

The penalty is calculated by dividing the total uncompensated value of transfers by the average monthly cost of nursing home care in Florida. In 2026, that divisor is approximately $10,645 per month. Give away $106,450 in the look-back period and the penalty runs roughly 10 months. The penalty clock doesn’t start until you’ve spent down to the asset limit and actually applied, which is where this gets painful: you may need nursing home care, have no money left to pay for it, and still face months of ineligibility because of a past gift. Common triggers include gifts to family members, adding a child’s name to a bank account, and paying off a relative’s debt. Planning with an elder law attorney well before care is needed helps avoid these traps.

How to Apply for Florida Medicaid

Applications go through DCF’s ACCESS Florida system. You can apply online through the MyACCESS portal, in person at a DCF service center or community partner location, or by mail or fax.¹¹ Processing takes up to 30 days for most applications, and longer when a disability determination is needed. An interview isn’t typically required for Medicaid-only applications, though DCF may ask for additional documentation. Approved applicants receive Florida’s gold Medicaid card in the mail.

You’ll need proof of Florida residency, citizenship or immigration status, identity, bank statements for all accounts, income verification, and asset documentation. For long-term care applications, gather five years of financial records because of the look-back.

If You’re Denied

Federal law requires Florida to offer a fair hearing when an application is denied or benefits are reduced. You have up to 90 days from the date on the denial notice to request one.¹² The hearing is conducted by an impartial official who wasn’t involved in the original decision. If you already receive benefits and file your hearing request before the effective date of a reduction or termination, your benefits generally continue at the current level until the hearing is resolved.

Estate Recovery After Death

After a Medicaid recipient dies, Florida is required to seek repayment from the estate for benefits paid on their behalf after age 55, under the Medicaid Estate Recovery Act.¹³ A home that was exempt during the recipient’s lifetime often becomes the state’s primary target after death.

Florida cannot pursue a claim if the recipient is survived by a spouse, a child under 21, or a child who is blind or permanently disabled. Recovery is also barred against property that is exempt from creditor claims under Florida law, such as protected homestead. When no exemption applies, heirs can request an undue hardship waiver, for instance by showing they lived in the home at the time of death and had resided there for at least 12 months beforehand.¹³ Planning tools like a lady bird deed or an irrevocable trust can protect a home from recovery, but they need to be in place well before the look-back period.

Qualifying for Both: Dual Eligibility and Medicare Savings Programs

People who qualify for both Medicare and full Medicaid are called dual eligibles. Medicare pays first, and Medicaid picks up remaining costs including deductibles, copays, coinsurance, and services Medicare doesn’t cover, such as long-term care. This coordination eliminates most out-of-pocket spending on health care.¹⁴

Even if you don’t qualify for full Medicaid, Florida offers four Medicare Savings Programs that help cover Medicare costs. Qualifying for any MSP also enrolls you automatically in Extra Help, a federal program that lowers Part D prescription drug costs.

Qualified Medicare Beneficiary (QMB) covers Part A and Part B premiums, deductibles, copays, and coinsurance. Income limit: $1,350 per month individual, $1,824 couple. Resource limit: $9,950 individual, $14,910 couple.¹⁵
Specified Low-Income Medicare Beneficiary (SLMB) pays the Part B premium only. Income limit: $1,616 individual, $2,184 couple. Same resource limits as QMB.¹⁵
Qualifying Individual (QI) also pays the Part B premium at slightly higher incomes. Income limit: $1,816 individual, $2,455 couple. Same resource limits. This program is first-come, first-served with limited funding.¹⁵
Qualified Disabled and Working Individual (QDWI) covers the Part A premium for people under 65 with a disability who lost premium-free Part A after returning to work. Income limit: $5,405 individual. Resource limit: $4,000 individual, $6,000 couple.¹⁵

Apply for MSPs through the same DCF ACCESS Florida system. The savings are substantial: QMB alone can put over $2,400 per year back in your pocket by eliminating premiums and cost-sharing, and Extra Help can save thousands more on prescriptions.

1
Medicare.gov. End-Stage Renal Disease (ESRD)
2
Social Security Administration. Sign Up for Medicare
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Medicare.gov. Avoid Late Enrollment Penalties
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Medicare.gov. Costs
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Medicare.gov. Get Ready to Buy
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FloridaHealthFinder. Medicaid – General Information
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Medicaid.gov. Eligibility Policy
8
Federal Register. Annual Update of the HHS Poverty Guidelines
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Social Security Administration. SSI Federal Payment Amounts for 2026
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Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets
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Florida DCF. Applying for Assistance
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eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
13
The Florida Legislature. Florida Code 409 – 0409.9101 Medicaid Estate Recovery Act
14
Medicaid and CHIP Payment and Access Commission. Dually Eligible Beneficiaries
15
Medicare.gov. Medicare Savings Programs