If you’re over 65, you qualify for Medicare, a federally funded program that also covers those under 65 with certain disabilities. Medicaid is a state-administered federal health insurance program for low-income individuals.
For the millions of people who qualify for both programs, Medicaid offers critical support for Medicare beneficiaries with limited incomes, helping to ease the financial burden of healthcare costs.
Knowing how these programs work together, and how recent updates may affect you, is key to understanding dual eligibility and your coverage options.
Full-Benefit vs. Partial-Benefit Dual Eligibility: What’s the Difference?
Approximately 13 million people are enrolled in both Medicare and Medicaid, according to a 2025 study in Medical Care Research and Review.
There are two main types of these dual-eligible beneficiaries:
— Full-benefit beneficiaries. These beneficiaries are eligible for Medicaid coverage for healthcare services that Medicare does not cover. They also receive coverage for premiums, deductibles, copays and coinsurance.
— Partial-benefit beneficiaries. These beneficiaries are eligible for Medicaid but receive restricted benefits, often to cover specific costs, which may include Medicare Part A or Part B premiums, deductibles and copayments.
KFF reports that nearly three-quarters of dual eligibles are full-benefit enrollees who receive comprehensive Medicaid services, including long-term care, which Medicare doesn’t cover. The remaining partial-benefit enrollees receive assistance primarily for Medicare premiums and cost-sharing.
Despite representing a small portion of overall beneficiaries, dual-eligible individuals account for a disproportionate share of both Medicare and Medicaid spending, with an estimated 33% of traditional Medicare and 32% of Medicaid expenditures, KFF notes.
Side-by-side comparison of dual-eligible benefits
| Category | Full-Benefit Dual Eligible | Partial-Benefit Dual Eligible |
| Medicare coverage | Parts A and B plus Part D. Beneficiaries may also enroll in a Medicare Advantage plan. | Parts A and B, but Part D coverage may be limited. Beneficiaries may also enroll in a Medicare Advantage plan. |
| Medicaid help | Covers what Medicare does not | Often covers specific costs, such as Part B premiums |
| Eligibility (varies by state) | Low income and low assets | Low income but higher assets (though amounts depend on the state) |
| Cost-sharing | Covered for Medicare-approved services | Helps with some costs |
| Care coordination | Can join fully integrated D-SNPs (dual-eligible special needs plans) | May join partially integrated D-SNPs or standard Medicare Advantage plans |
[Read: Medicare Advantage vs. Medicare Cost Plans 2026: Costs, Coverage and How to Choose]
How to Qualify for Medicare-Medicaid Dual Eligibility in 2026
Medicare and Medicaid eligibility are handled and determined separately. The general process for applying for both, however, involves the following steps.
Step 1: Meet Medicare eligibility and enrollment requirements
Most beneficiaries sign up for Medicare during the initial enrollment period, which starts three months before their 65th birthday and ends three months afterward.
You may also qualify to receive Medicare benefits regardless of age if:
— You have a disability that prevents you from working and you are receiving Social Security disability benefits
— You live with end-stage renal disease
— You have amyotrophic lateral sclerosis
When the time comes to apply for Medicare, you can:
— Enroll online through the Social Security Administration’s (SSA) website
— Call the SSA at 1-800-772-1213
— Visit a local Social Security office in person. The Social Security website has a “Find an Office” tool that will help you locate the nearest one.
Step 2: Apply for Medicaid and check state income and asset limits
Applying for Medicaid involves determining eligibility
and submitting an application through your state’s Medicaid office. Since each state manages its own Medicaid programs, rules and requirements vary. Use tools like the Medicaid eligibility checker on HealthCare.gov or your state’s Medicaid website to see if you qualify.
Medicare beneficiaries can become eligible for Medicaid if they meet specific income and asset requirements set by their state:
— Income limits. To qualify for Medicaid, beneficiaries must have income that is below a certain level (which varies by state). Generally, individuals must have an income at or below 100% to 138% of the federal poverty level to qualify.
— Asset limits. Medicaid also considers assets, or “resources,” which may include savings, property and investments. The asset limits are typically lower than the income limits. For example, in many states, individuals must have assets below $2,000 for an individual or $3,000 for a couple, though some states may allow higher limits or exclude certain assets, such as a primary home.
— Level of need. Some Medicaid benefits, like long-term care or home- and community-based services, may require an assessment of functional limitations or medical necessity.
Depending on income levels, you may qualify for Medicare Savings Programs that assist with Medicare expenses.
| Program | 2026 Income Eligibility Limit (% of the Federal Poverty Level) | What It Helps Cover |
| Qualified Medicare Beneficiary | At or below 100% | Medicare premiums, deductibles, coinsurance and copayments |
| Specified Low-Income Medicare Beneficiary | Between 100% and 120% | Medicare Part B premium ($202.90 in 2026) |
| Qualifying Individual | Between 120% and 135% | Medicare Part B premium, though funding is limited and provided on a first-come, first-served basis |
| Qualified Disabled and Working Individual | Up to 200% | Medicare Part A premium ($311 or $565 per month in 2026) for disabled beneficiaries under age 65 who returned to work and lost premium-free Part A |
Step 3: Select your plan option (original Medicare vs. integrated D-SNP)
After being approved for Medicaid, you are automatically considered “dual eligible,” and there is not a separate third application to tie the two programs together. You can stay on original Medicare (Part A and Part B), with Medicaid helping to pay costs, or you can choose to enroll in a dual-eligible Special Needs Plan (D-SNP), a specialized type of Medicare Advantage plan designed exclusively for people who qualify for both Medicare and Medicaid.
Keep in mind that state-specific approaches mean that dual-eligible beneficiaries can have very different experiences depending on where they live. For instance:
— In New York: Access to integrated coverage often depends on county-level programs like IB-Dual or Medicaid Advantage Plus, so some beneficiaries may have multiple plan choices, while others must manage Medicare and Medicaid separately.
— In California: The statewide expansion of Medi-Medi Plans means more dual eligibles can enroll in a single coordinated plan that manages both Medicare and Medi-Cal benefits under one insurer.
[READ: How to Qualify for Medicaid Long-Term Care: The Spend-Down Guide]
2026 Medicare-Medicaid Rule Changes: D-SNPs, SEPs and Appeals
Navigating the Medicare and Medicaid landscape can be particularly difficult for beneficiaries who qualify for both.
“Dual-eligible beneficiaries have dealt with a highly complex system, with Medicare covering medical and pharmacy needs, while Medicaid addresses costs, like premiums, copays and long-term care,” says Eric Roberts, an associate professor at the University of Pennsylvania’s Perelman School of Medicine and a senior fellow at the Leonard Davis Institute of Health Economics. “This intricate overlap has historically created challenges in coordinating care, ensuring coverage and managing costs for a vulnerable population with significant health and financial needs.”
Recent policy changes, however, aim to streamline the program and make it easier for individuals to better understand how to access their benefits.
What are integrated D-SNPs and how do they work?
Under new Centers for Medicare & Medicaid Services (CMS) guidance, D-SNPs are prioritized as the preferred coverage model for people who are dually eligible. Rather than treating Medicare and Medicaid as different entities, D-SNPs bundle care coordination, combining hospital, medical and prescription drug coverage with care management, aligned provider networks and support for medical, behavioral health and long-term care needs.
Plans must now provide one ID card for both Medicare and Medicaid, conduct a single integrated health risk assessment and follow set timelines for creating individualized care plans with input from beneficiaries.
Monthly special enrollment period (SEP) rules for 2026
Depending on your eligibility, you can now switch plans monthly. In 2025, CMS ended the long-standing special enrollment period (SEP) that previously allowed dual-eligible beneficiaries to switch Medicare Advantage or Part D plans every three months. In its place, CMS created a monthly integrated care SEP, which, in 2026, continues to allow full-benefit beneficiaries to change plans only if they are moving into an integrated D-SNP, specifically a fully integrated, highly integrated or applicable-integrated plan. This change reflects CMS’s intent to steer enrollment toward plans that deliver truly integrated, person-centered care rather than loosely coordinated coverage.
How the unified appeals process works for dual eligibles
Under CMS’s integrated care requirements, D-SNPs now must administer a unified appeals and grievance process for members whose benefits are aligned under the same plan. This change removes the frustrating burden of figuring out whether a problem should be handled by Medicare or Medicaid.
Now, beneficiaries file a single appeal or grievance through their plan. They no longer need to submit separate appeals or work with two different agencies. The plan is responsible for coordinating the review, applying the correct Medicare and Medicaid requirements and working with the state Medicaid agency when necessary.
CMS expects the unified process to simplify dispute resolution, reduce administrative burden and make it easier for dual-eligible individuals to challenge coverage decisions without unnecessary delays or paperwork.
VBID transition to SSBCI supplemental benefits in 2026
CMS ended the Medicare Advantage Value?Based Insurance Design (VBID) model in 2025. Under VBID, plans had greater flexibility to offer broad supplemental benefits, often called “wallets,” for items such as groceries, utilities or transportation, based on criteria beyond just health status.
In 2026, many of the nonmedical supports that beneficiaries value continue through Special Supplemental Benefits for the Chronically Ill (SSBCI) but with stricter eligibility rules. Unlike VBID, SSBCI benefits generally can only be offered to enrollees who have one or more documented chronic conditions, such as diabetes, chronic heart failure or COPD, and the benefit must be expected to improve or maintain health or overall function.
[READ: How Medicare Beneficiaries Can Save Money on Prescription Drugs]
How to Maintain Your Dual-Eligible Status and Annual Renewals
Remaining dual eligible for both Medicare and Medicaid requires meeting the financial and program-specific criteria for each program. Once you’re enrolled, Medicare coverage is permanent. However, different states have different annual reenrollment or renewal requirements for Medicaid, so check with your state’s Medicaid office.
“The process ensures that beneficiaries still meet the eligibility requirements, particularly by verifying income and asset levels,” Roberts says. “The reenrollment process and timing varies by state.”
Medicaid beneficiaries are required to keep countable assets like savings, investments or secondary properties within the state’s limits.
Where to Get Free Help: SHIP, AAA and Community Resources
With recent changes reshaping the system, choosing the best plan can feel confusing and raise questions. The good news is that there is plenty of free help out there.
“There are several state-level resources available to help individuals navigate the complexities of dual eligibility,” Johnston says.
Some organizations include:
— Administration for Community Living (ACL). The ACL is a federal agency that works to promote the well-being and independence of older adults and individuals with disabilities. Through partnerships with state and local organizations, the ACL ensures access to resources and services that can assist with understanding and applying for dual-eligibility programs.
— Area Agencies on Aging (AAA). Area Agencies on Aging are community-based organizations that offer support tailored to older adults. They provide a wide range of services, including assistance with Medicare and Medicaid enrollment, understanding benefits and connecting individuals to local resources. These agencies can be especially helpful for figuring out the eligibility requirements for dual programs.
— State Health Insurance Assistance Programs (SHIP). SHIPs are free counseling programs available in every state, and they are designed to help Medicare beneficiaries understand their coverage options. SHIP counselors provide unbiased, one-on-one assistance with topics like Medicare benefits, Medicaid dual eligibility, enrollment processes and billing issues. SHIP services are particularly valuable for those who need help coordinating the benefits of both programs.
Frequently Asked Questions About Medicare-Medicaid Dual Eligibility
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What Is Medicare-Medicaid Dual Eligibility? originally appeared on usnews.com
Update 07/27/26: This story was published at an earlier date and has been updated with new information.
