Medicare and Medicaid Dual Eligibility

Dual Eligibility Benefits and Coordination

Individuals enrolled in both Medicaid and Medicare can receive greater healthcare coverage and lower out-of-pocket costs. Medicare serves as the primary payer for medical expenses and hospitalization. If Medicare does not cover the full cost, Medicaid acts as the secondary payer to cover the remaining gaps. Additionally, Medicaid covers services that Medicare typically does not, including:

• Personal care assistance (in-home and community-based)

• Long-term skilled nursing home care

For those who qualify for both programs, enrolling in a offers a streamlined way to manage your care. A primary option designed specifically for dual-eligible individuals is a Dual-Eligible Special Needs Plan (D-SNP).

D-SNPs are specialized Medicare Advantage plans that consolidate your Medicare Part A, Part B, and Part D prescription drug coverage into a single coordinated network while aligning directly with your state Medicaid benefits.

Key advantages of D-SNPs include:

• Care Coordination: D-SNPs provide access to dedicated care managers who assist in scheduling appointments, managing prescriptions, and navigating both Medicare and Medicaid networks.

• Minimal Out-of-Pocket Costs: Because Medicaid covers most cost-sharing responsibilities, enrollees often pay $0 premiums and low-to-no copays for covered medical services and prescription drugs.

• Enhanced Supplemental Benefits: D-SNPs frequently offer extra benefits beyond Original Medicare, such as allowance credits for healthy groceries or utilities, over-the-counter (OTC) health products, comprehensive dental, routine vision, and non-emergency medical transportation.

Upcoming D-SNP Alignment Rules: The "No Mix-and-Match" Mandate

The Centers for Medicare & Medicaid Services (CMS) is phasing in new alignment requirements to eliminate fragmented care for dual-eligible beneficiaries. Historically, beneficiaries could "mix and match"—choosing a Medicare D-SNP from one private insurer while receiving Medicaid coverage from a completely separate insurance company.

To streamline benefits and improve health outcomes, CMS is ending unaligned enrollment:

• Unified Insurance Carriers: Starting in 2027, new D-SNP enrollees will no longer be allowed to split their coverage between two different parent organizations. If you select a private Medicare D-SNP, you must use that same insurance company (or its affiliated Medicaid plan) for your Medicaid coverage.

• Elimination of Unaligned Plans: By 2030, all existing dual-eligible beneficiaries enrolled in D-SNPs must transition to exclusively aligned plans, unifying Medicare Part A, Part B, Part D, and Medicaid benefits under a single managed care provider.

• Simplified Care Administration: Single-carrier alignment ensures a single point of contact for claims, a unified network of doctors, and seamless care management across both programs.

You don't have to navigate changing state and federal regulations on your own. SelectQuote licensed insurance agents handle the heavy lifting by comparing aligned D-SNP options from top carriers in your area. We'll help you find a plan that lets you keep your preferred doctors, hospitals, and prescriptions—ensuring seamless coverage well before federal deadlines arrive. 

How to Apply for Dual Eligibility

To apply for Medicare, contact your local Social Security Administration office. To find out if you’re eligible for Medicaid and to apply, contact your state’s Medicaid agency.