Are You Dual Eligible? Find Your Best Medicare and Medicaid Options

What is Dual Eligibility?

Dual eligibility refers to individuals who qualify for both Medicare and Medicaid benefits. Typically, these are low-income seniors or people with disabilities who meet the income and asset requirements set by their state’s Medicaid program while also qualifying for Medicare due to age or disability. Medicare serves as the primary insurer, covering hospital and medical care, while Medicaid helps with out-of-pocket costs like premiums, copays, and services not fully covered by Medicare.

What is Partial-Benefit Dual Eligibility?

Some people qualify for Medicare and receive limited Medicaid assistance — these individuals are called partial-benefit dual eligibles. They typically get help from Medicare Savings Programs (MSPs) to pay for Medicare premiums and cost-sharing, but do not receive full Medicaid benefits like long-term care or in-home services.

A person may receive limited Medicaid assistance if their income or assets are too high to qualify for full Medicaid, but still low enough to get help with Medicare costs through an MSP. These individuals are often considered low-income, but just above the threshold for full Medicaid coverage.

What Additional Benefits Can You Get as a Dual Eligible?

Dual eligible individuals often receive more comprehensive coverage than those with Medicare or Medicaid alone. In addition to standard Medicare benefits like hospital, doctor, and preventive care, dual eligibles may receive Medicaid support for premiums, copays, and deductibles, as well as services like long-term care, home health, personal care, and transportation to medical appointments. This combination helps reduce out-of-pocket costs while expanding access to services that support daily living and overall health.

Those enrolled in Dual Eligible Special Needs Plans (D-SNPs) or plans with Integrated Care Options (such as FIDE-SNPs, HIDE-SNPs, or state-run programs) may get even more enhanced benefits. These can include dental, vision, hearing aids, fitness programs, transportation, and over-the-counter (OTC) allowances to buy health-related products that may include groceries. Integrated plans often come with care coordination, 24/7 nurse lines, case management, and a single card for both Medicare and Medicaid services—making it easier to manage care.

Individuals who are partial-benefit dual eligibles may not receive all these extras. Because they do not qualify for full Medicaid, some services like long-term care, in-home support, or certain waiver programs may not be included. If a partial-benefit dual enrollee joins a D-SNP, they may still get core Medicare Advantage benefits and some added extras like OTC allowances or dental, but will not receive Medicaid-covered services that require full eligibility.

How to Find Out If You Qualify for Dual Eligibility?

You are considered dual eligible if you qualify for Medicare and also meet your state’s income and asset requirements for Medicaid. This combined eligibility gives you access to both programs, helping reduce out-of-pocket costs and expand your benefits.

To qualify, you must be enrolled in Medicare – either by being 65 or older or having a qualifying disability or medical condition – and your income and resources must fall within your state’s limits for full Medicaid or a Medicare Savings Program (MSP). These limits vary by state and by the level of assistance you’re applying for.

Resources to Help Determine Your Eligibility

If you are unsure where to begin, here are trusted resources that can help you assess your eligibility for Medicare, Medicaid, or both. These tools and services provide guidance on requirements, benefits, and how to get started.

1. Medicare Eligibility

• Online: Visit Medicare.gov's Medicare Eligibility & Premium Calculator to estimate your eligibility and potential premiums.
• Phone: Call 1-800-MEDICARE (800-633-4227) for assistance.

2. Medicaid Eligibility

Medicaid programs differ by state. Contact your state's Medicaid office to help determine your eligibility. You can find your state Medicaid agency's website link and phone number by clicking this resource, to access the comprehensive list provided by The Hemophilia Federation of America.

Additionally, the American Council on Aging offers detailed information on state-specific Medicaid programs, including alternative program names and contact details, available at State Medicaid Resources.

3. Personalized Assistance through State Health Insurance Assistance Program (SHIP)

• Online: Visit the official SHIP website. On the homepage, click on the “SHIP Locator” link and choose your state to find contact information for your local SHIP office, including phone numbers, email, and websites.
• Phone: Call 1-877-839-2675 to connect with a SHIP counselor in your area.

Looking for local support and help?

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What Healthcare Options are Available for Dual Eligibles?

If you're eligible for both Medicare and Medicaid, you have several healthcare coverage options. These vary in how benefits are delivered and coordinated. The three main options are:

1. Original Medicare + Medicaid
2. Dual Eligible Special Needs Plans (D-SNPs)
3. Integrated Care Options (HIDE-SNPs, FIDE-SNPs, MMPs, and state-run programs)

The key difference between these options comes down to the level of integration between Medicare and Medicaid. The more integrated the plan, the more it is designed to deliver coordinated, simplified care – though the actual experience may vary depending on the plan and location.

1. Original Medicare + Medicaid

This option gives you coverage through Medicare for hospital and medical services and Medicaid for additional support, such as premiums, copays, and long-term care. However, the two programs operate separately, which can make care harder to manage and less coordinated.

2. Dual Eligible Special Needs Plans (D-SNPs)

A D-SNP is a type of Medicare Advantage plan tailored for people with both Medicare and Medicaid. It offers coordinated benefits, but in most cases, Medicaid services are still handled separately. These plans often include extras like dental, vision, care management, and over-the-counter (OTC) allowances.

Want to learn more about Medicare Advantage?

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3. Integrated Care Options

These plans combine both Medicare and Medicaid benefits into unified coordinated care. Options include Fully Integrated D-SNPs (FIDE-SNPs), Highly Integrated D-SNPs (HIDE-SNPs), Medicare-Medicaid Plans (MMPs), and state-run integrated programs. They offer simplified access, strong care coordination, and one point of contact for all services.

Not all integrated care plans are available in every state, and even within participating states, availability may be limited to certain counties or regions. However, CMS is actively working with states and health plans to expand access to more integrated options as part of its long-term goal to improve care for dual-eligible individuals nationwide.

Fully Integrated D-SNPs (FIDE-SNPs)

FIDE-SNPs are the most integrated type of Dual Eligible Special Needs Plan. These plans combine all Medicare and Medicaid benefits, including long-term services and supports (LTSS) and behavioral health, under a single organization. Enrollees typically have one card, one provider network, and a coordinated care team that manages all aspects of their health. FIDE-SNPs offer comprehensive coverage, streamlined billing, and enhanced care coordination.

Currently available in: AZ, CA, FL, HI, ID, MA, NJ, NY, TN, VA, WI

Highly Integrated D-SNPs (HIDE-SNPs)

HIDE-SNPs offer a moderate level of integration between Medicare and Medicaid. These plans coordinate Medicare services and contract with state Medicaid programs to manage some Medicaid benefits, such as LTSS or behavioral health. While not fully integrated, HIDE-SNPs still provide strong care coordination, helping enrollees navigate both programs more easily.

Currently available in: AZ, DC, FL, HI, IA, IN, KS, KY, MN, NE, NM, NY, OR, PA, PR, TX, VA, WA, WI

Medicare-Medicaid Plans (MMPs)

MMPs are part of a federal demonstration project created under the CMS Financial Alignment Initiative, designed to fully integrate Medicare and Medicaid benefits into a single health plan. MMPs offer one point of contact, comprehensive benefits, and strong care coordination. They are available only in select states and typically serve specific age groups or regions.

Currently available in: IL, MA, MI, NY, OH, RI, SC, TX, VA

IMPORTANT NOTE: CMS finalized a rule in 2022 to phase out MMPs by the end of 2025. Each state is now working with CMS to transition enrollees to more sustainable, long-term models — primarily integrated D-SNPs like FIDE-SNPs and HIDE-SNPs. States are at varying stages of this transition, with full migration expected by January 1, 2026.

State-Run Integrated Programs

Several states operate their own Medicare-Medicaid integrated care models outside of the national D-SNP or MMP frameworks. These state-run programs are designed specifically for dual eligibles and often feature full integration of Medicare and Medicaid benefits, strong care coordination, and access to long-term services and supports (LTSS). These programs are typically available only in certain counties or age groups and are administered through state partnerships with health plans that meet strict integration standards.

Examples of state-run integrated programs include:

• California: CalAIM (transitioning to enhanced D-SNPs)
• Massachusetts: Senior Care Options (age 65+), One Care (ages 21–64)
• Michigan: MI Health Link (age 21+, planned phase-out after 2025)
• Minnesota: Minnesota Senior Health Options (age 65+)
• New York: Medicaid Advantage Plus (MAP) (age 18+)
• Rhode Island: INTEGRITY (age 21+)
• Texas: STAR+PLUS
• Washington: Fully Integrated Managed Care
• Wisconsin: Partnership Program

What costs do enrollees pay under each dual eligible option?

While dual eligibles receive significant help with healthcare costs, the out-of-pocket expenses can vary depending on the type of plan you’re enrolled in. Here's a breakdown of what you might pay under each option:

1. Original Medicare + Medicaid

• Medicaid may cover Medicare Part B costs such as premiums, deductibles, and copays – depending on your income level and state rules.
• Prescription drugs may be covered through Medicare Part D or state Medicaid, often with low or no copays.
• If you receive full Medicaid, most costs are covered. Partial Medicaid may offer only limited cost-sharing assistance.

2. Dual Eligible Special Needs Plans (D-SNPs)

• Many D-SNPs offer $0 monthly premiums, as Medicaid often pays the Medicare Advantage premium.
• You may pay low or no copays for doctor visits, hospital stays, and prescriptions.
• OTC items and extras like dental or vision are often included at no additional cost.
• Costs can vary slightly by plan and state, but most D-SNPs are very affordable for dual eligibles.

3. Integrated Care Options (FIDE-SNPs, HIDE-SNPs, MMPs, State Programs)

• Typically offer the lowest and most predictable costs of all three options.
• $0 premiums, minimal or no copays, and full drug coverage are common.
• Since both Medicare and Medicaid benefits are integrated, billing is simpler and there’s less risk of surprise charges.

All three options aim to minimize your healthcare costs, but the level of integration impacts how streamlined and predictable those costs are. Integrated care options generally provide the most financial protection, followed by D-SNPs, while Original Medicare + Medicaid may require more navigation to manage out-of-pocket expenses.

Which Option Should You Choose?

Choosing the right healthcare option depends on your needs, what’s available in your state, and how much help you want managing your care. Here’s a quick look at the pros and cons of each path for dual eligibles:

1) Original Medicare + Medicaid

Pros:

• Broad access to providers who accept Medicare and Medicaid
• Automatically available if you qualify for both programs
• No plan enrollment required

Cons:

• Medicare and Medicaid operate separately, which may cause confusion
• No care coordination or case management
• Fewer extra benefits like dental or vision
• Must manage two different systems of coverage

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

Pros:

• Coordinated Medicare and Medicaid coverage
• Often includes extra benefits like dental, vision, and hearing
• Many plans offer a monthly OTC allowance for health-related products that may include groceries.
• Access to care managers and support services

Cons:

• Provider networks may be limited to the plan
• Medicaid services are still managed separately
• You must enroll in a plan and confirm eligibility

3) Integrated Care Options (FIDE-SNPs, HIDE-SNPs, MMPs, State Programs)

Pros:

• Most seamless experience – one card, one plan, one team
• Full benefits integration of Medicare and Medicaid
• Strong care coordination and extra services
• Simplifies billing, scheduling, and communication

Cons:

• Availability is limited to specific states and counties
• Must enroll in a specific plan (may need to switch providers)
• Some programs are age-restricted or phasing out (MMPs)

Use the comparison table below to help you decide which option fits your situation best.

How Can Hesteon Help You Navigate Dual Eligibility Options?

At Hesteon Solutions, we specialize in helping individuals who qualify for both Medicare and Medicaid understand and choose the coverage that best fits their needs. Dual eligibility comes with unique opportunities and complexities, and our licensed agents are here to simplify it for you.

Whether you’re newly eligible, trying to understand D-SNPs or integrated care plans, or need help determining your Medicaid status, we offer personalized guidance every step of the way. We’ll help you compare options, verify eligibility, and enroll in a plan that coordinates your benefits while maximizing your coverage and minimizing your costs.

Contact us today for a free consultation and let us help you navigate dual eligibility with confidence!

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