Dual Eligible for Medicare and Medicaid? Your Coverage Options May Have Changed
Key Takeaways
- If you’re dual eligible for Medicare and Medicaid, you may have the option to join a Dual Eligible Special Needs Plan (D-SNP).
- The Centers for Medicare and Medicaid Services (CMS) have made changes to rules for D-SNP coverage and enrollment.
- For some plans, CMS now requires more integration between Medicare and Medicaid coverage.
- Dual eligible individuals now have access to fewer Special Enrollment Periods when they can make changes to their coverage.
Dual eligibility is when someone on Medicare also qualifies for Medicaid. Medicare is the public health insurance program for U.S. adults who are over 65 or have certain disabilities. Medicaid is a separate health insurance program for people with limited incomes. If you’re eligible for both Medicare and Medicaid, you can join a type of Medicare Advantage plan called a Dual Eligible Special Needs Plan (D-SNP).
Private insurance carriers offer Medicare Advantage plans as an alternative to the federally administered coverage from Original Medicare. Medicare Advantage plans often feature additional benefits. Special Needs Plans are designed for specific types of beneficiaries. In addition to D-SNPs, there are Chronic Condition Special Needs Plans (C-SNPs) for those living with a chronic disease and Institutional Special Needs Plans (I-SNPs) for those receiving long-term care.
In 2024, nearly 6 million people were on D-SNPs, which must include Medicare Part D prescription drug coverage and may also provide services and savings to address the health needs of people with lower incomes.
There are significant updates to D-SNP enrollment and coverage options in 2025. If you’re a dual-eligible enrollee, understanding these changes can help you make the best choices about your health coverage.
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Who Qualifies for Dual Eligibility?
To join a D-SNP, you must be enrolled in Original Medicare (Medicare Parts A and B) or another Medicare Advantage plan and qualify for Medicaid.
You’re eligible for Medicare if you are a U.S. citizen or permanent resident who meets any of the following criteria:
- You are at least 65 years old.
- You have received Social Security disability or Railroad Retirement Board benefits for 24 consecutive months.
- You have end-stage renal disease or amyotrophic lateral sclerosis.
Medicaid, on the other hand, is for people who have low incomes and meet other eligibility requirements. Since individual states administer these programs, the precise criteria and coverage details vary.
Medicare Advantage plan availability, including for D-SNPs, also depends on where you live. There’s a selection of plans in every ZIP code, each associated with a local provider network (including doctors, hospitals, and pharmacies) to control expenses and offer coordinated care. Insurance carriers offered 851 D-SNP plans nationwide as of 2024.
Increasing D-SNP Integration
There are a few different types of D-SNPs, distinguished by how fully they integrate Medicare and Medicaid benefits:
- Coordination only: This type of D-SNP only provides Medicare-covered services and coordinates benefits delivery with the state Medicaid program.
- Highly integrated: With this D-SNP type, the insurance carrier has its own Medicaid plan to provide both Medicare and Medicaid services. However, there’s no requirement to enroll in both the plans from the carrier; you can continue to receive benefits through your state’s Medicaid’s plan.
- Fully integrated: This type of D-SNP offers a Medicaid-managed care plan incorporating Medicare benefits with an aligned care management strategy. This plan is intended to achieve lower costs and better patient outcomes with a single system to manage benefits, communications, and coordinated care from multiple providers.
- Applicable integrated plan: Any of the above types of plans can be considered an applicable integrated plan if it has aligned enrollment in a Medicaid plan, covers some Medicaid benefits, and provides a unified appeals and grievances process for both forms of coverage.
The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers the public health insurance programs, is making policy changes to promote integration and simplify coverage for consumers. In the past, dual eligible Medicare consumers could join a fully integrated D-SNP without enrolling in the associated Medicaid plan. As of 2025, if you enroll in a fully integrated D-SNP, you must join the Medicaid plan from that insurance carrier.
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D-SNP Special Enrollment Period Changes
People on Medicare can make changes to their coverage during the Annual Enrollment Period, from Oct. 15 through Dec. 7, or during Special Enrollment Periods triggered by certain situations.
Before 2025, dual eligibility meant that you had a quarterly Special Enrollment Period when you had the option to change Medicare Advantage plans. That period no longer applies, but there are two new Special Enrollment Periods:
- Integrated Care Special Enrollment Period: If you’re dual eligible and qualify for full Medicaid benefits, you can use a monthly Special Enrollment Period to enroll in a fully integrated D-SNP, a highly integrated D-SNP, or an applicable integrated plan. This period is designed to encourage more integrated coverage and can only be used if you’re enrolling in (or have already joined) the insurance carrier’s aligned Medicaid managed care plan.
- Dual Eligible/Low Income Subsidy Special Enrollment Period: Once per month, this Special Enrollment Period is open to two groups of people:
- Current enrollees in a Medicare Advantage plan who are dual eligible can leave their plan and go back to Original Medicare while joining a standalone Medicare Part D prescription drug plan.
- People on Original Medicare who receive Extra Help (also called the Low Income Subsidy) to help with the costs of Medicare Part D prescription coverage can switch from one Part D plan to another.
Navigating your enrollment and coverage options can be complicated when you’re dual eligible, but the right plan can provide valuable benefits. Talk with a licensed insurance agent to find out whether there’s a D-SNP in your area that’s right for you.