Key Takeaways

• If you qualify for both Medicare and Medicaid, you may receive broader health coverage and help with out-of-pocket costs—but you must apply for Medicaid separately.

• In 2025, dual eligibility can open access to specialized plans and services, but you need to understand the enrollment rules, benefits, and limitations to make the most of them.

What Dual Eligibility Really Means

Dual eligibility means you’re eligible for both Medicare and Medicaid at the same time. Medicare is a federal program primarily for people aged 65 and older or with qualifying disabilities. Medicaid is a state-based program for those with limited income and resources. Together, they can offer a more complete health coverage solution—but they don’t merge into one program.

In 2025, there are more tools and support than ever to help you understand how to combine these benefits—but the process still requires careful planning. Medicare usually pays first for services that both programs cover. Medicaid then steps in to help with costs Medicare doesn’t fully pay for, such as premiums, deductibles, coinsurance, and even long-term care.

Who Can Qualify for Both Programs in 2025?

To be dual eligible in 2025, you must meet the eligibility requirements for both programs individually:

Medicare Eligibility

• Age 65 or older, or

• Under 65 with a qualifying disability or end-stage renal disease (ESRD)

Medicaid Eligibility

• Income and asset limits vary by state, but generally include:

  • Monthly income under a specific threshold (usually tied to the Federal Poverty Level)

  • Limited countable assets (such as savings, not including your home or car)

Each state sets its own Medicaid rules, so you’ll need to check with your state’s Medicaid office to determine exact eligibility.

Types of Dual Eligible Individuals

Not all dual eligible beneficiaries get the same level of Medicaid help. There are different categories, based on your income and assets:

1. Full Benefit Dual Eligible (FBDE)

You get full Medicaid benefits, which may include:

• Help paying Medicare premiums, deductibles, and copayments

• Long-term care services (like nursing home or home health care)

• Dental, vision, and transportation (depending on your state)

2. Partial Benefit Dual Eligible

You qualify for a Medicare Savings Program (MSP), which helps with:

• Medicare Part B premium

• Possibly Medicare Part A premium (if applicable)

• Some coinsurance and deductible assistance

There are four main MSP categories in 2025:

• Qualified Medicare Beneficiary (QMB)

• Specified Low-Income Medicare Beneficiary (SLMB)

• Qualifying Individual (QI)

• Qualified Disabled and Working Individuals (QDWI)

Each program has specific income and asset limits that are adjusted annually.

What You Can Get Through Dual Eligibility in 2025

Combining Medicare and Medicaid doesn’t just prevent high out-of-pocket costs—it can enhance your access to services you may otherwise go without. Here’s what dual eligible beneficiaries can typically receive:

• Medicare-covered services: Hospital stays, doctor visits, preventive care, skilled nursing, and prescription drugs (under Part D)

• Medicaid-covered services: Long-term care, personal care services, adult daycare, dental, vision, and more—depending on your state

• Help with costs: Medicaid may pay Medicare Part A and Part B premiums, deductibles, and coinsurance

• Access to integrated plans: You may qualify for special plans that combine Medicare and Medicaid benefits into one coordinated package

Understanding Dual-Eligible Special Needs Plans (D-SNPs)

If you are dual eligible in 2025, you may have access to a type of Medicare Advantage plan called a Dual-Eligible Special Needs Plan (D-SNP). These plans are tailored specifically to people with both Medicare and Medicaid, and they coordinate benefits between the two programs.

D-SNPs must cover everything Original Medicare covers, and they often include:

• Care coordination

• Drug coverage

• Additional benefits like dental, hearing, or vision

• Help with transportation to appointments

You must remain eligible for both Medicare and Medicaid to stay enrolled in a D-SNP. If you lose Medicaid eligibility, you typically have a Special Enrollment Period to choose another Medicare plan.

Enrollment: It’s Not Automatic

Even if you’re eligible for both Medicare and Medicaid, dual eligibility is not automatic. You must enroll in both programs separately.

Enrolling in Medicare

• Initial Enrollment Period: A 7-month window around your 65th birthday

• Special Enrollment Periods: If you delayed enrollment due to other coverage

• General Enrollment Period: January 1 to March 31, with coverage starting July 1

Applying for Medicaid

• Apply through your state’s Medicaid agency

• Applications may be submitted online, by mail, or in person

• You’ll need documentation such as income statements, Social Security details, and asset information

Each state reviews Medicaid eligibility regularly, and you may need to recertify annually.

How to Start the Process in 2025

To determine your eligibility and apply for both programs:

1. Check Medicare enrollment status – If you’re already receiving Social Security benefits, you’re likely auto-enrolled in Medicare Part A and Part B.

2. Contact your state Medicaid office – This is the only way to determine if you qualify for Medicaid in your state. Use your state’s website or helpline.

3. Explore Medicare Savings Programs – If you don’t qualify for full Medicaid, you might still get help through a Medicare Savings Program.

4. Look into D-SNP availability – If you’re dual eligible, a D-SNP may coordinate your care more effectively. Availability depends on your location.

5. Keep documentation ready – Including tax returns, proof of income, utility bills, ID, and bank statements.

What to Watch Out for in 2025

Dual eligibility can provide important financial and health coverage benefits, but there are still risks if you aren’t careful:

• Loss of Medicaid eligibility: If your income or assets increase, you could lose benefits. Annual redeterminations are required.

• Provider confusion: Some doctors may not accept Medicaid, even if they accept Medicare. Confirm before scheduling visits.

• Coverage gaps: If you switch plans or lose Medicaid, you could have periods without coordinated care.

• Plan marketing: You may receive offers for plans that don’t coordinate Medicare and Medicaid effectively. Ask questions before enrolling.

Why This Matters for You Now

In 2025, with the cost of healthcare rising and the complexity of medical care increasing, dual eligibility provides a rare opportunity for comprehensive protection. But it only works in your favor if you:

• Understand your state’s Medicaid criteria

• Keep track of Medicare enrollment windows

• Review your plan options annually

You don’t need to navigate it alone. Licensed agents can explain how the programs work together, help you understand your benefits, and assist with enrollment.

Take Charge of Your Dual Eligibility Options

You could qualify for broader coverage and financial help—but only if you take the right steps to enroll in both Medicare and Medicaid. Understanding how they interact in 2025 can help you avoid surprises, reduce your out-of-pocket costs, and ensure you get the care you need.

Need help sorting through your options? Get in touch with a licensed agent listed on this website for assistance tailored to your situation.