If You Have Medicare and Medicaid

About 12 million Americans are covered by both Medicare and Medicaid at the same time. If you are one of them, you have two programs that were designed separately, often run by different agencies, and have never been fully connected. Getting them to work together for your benefit has been one of the more complicated challenges in American health policy, and the federal government has spent the past several years building new tools to do it better. Some of those tools are now in your hands.

What Dual Eligible Means

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Medicare is a federal program that covers medical care for people 65 and older and for younger people with certain disabilities. It pays for doctor visits, hospital stays, skilled nursing care, and prescription drugs. Medicaid is a joint federal-state program that covers people with low incomes. It can pay for things Medicare does not cover, including dental care, transportation to appointments, personal care aides, and long-term services that help you stay at home or in a community setting.

When you have both programs, Medicare pays first and Medicaid fills in some of what Medicare leaves out. The problem is that these programs do not naturally communicate with each other. A doctor billing Medicare does not automatically know about the Medicaid services you are also receiving. The home health agency helping you with daily activities may not be connected to your Medicare Advantage plan. The result can be care that is fragmented, gaps in coverage, and confusion about what each program covers and who to call when something goes wrong.

The solution CMS has been building is a category of plans called Dual Eligible Special Needs Plans, or D-SNPs. These are Medicare Advantage plans specifically designed for people who have both programs. A more integrated version, called a Fully Integrated Dual Eligible Special Needs Plan or FIDE SNP, goes further: it wraps Medicare and Medicaid coverage into a single plan with a single care team, a single point of contact, and coordinated benefits. A FIDE SNP should know about all of your services across both programs because it is managing both of them.

A FIDE SNP typically covers services that a regular Medicare Advantage plan does not, including long-term services and supports like personal care assistance and adult day programs, behavioral health coordination, and more comprehensive transportation and social support. Not every state has FIDE SNPs available, and not every county within a state that has them will have multiple options. But if you are dual eligible and a FIDE SNP is available where you live, it is worth understanding what it offers compared to what you currently have.

The Monthly Switch Option

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For most Medicare beneficiaries, you can only change your plan during the Annual Enrollment Period that runs from October through December. If you have both Medicare and Medicaid, that rule changed. You now have the right to switch your Medicare Advantage plan once per month, every month of the year. This is called the monthly Special Enrollment Period for dual eligible individuals.

This protection exists because dual eligible beneficiaries have historically been enrolled in plans that did not serve them well, sometimes without fully understanding what they were signing up for. The monthly option gives you an exit route whenever you discover a plan is not meeting your needs.

The harder practical challenge is using this right wisely. When a new flexibility exists in the Medicare enrollment system, it creates a business opportunity for agents and brokers who sell Medicare plans. If you are dual eligible, you may receive more calls, more door-to-door visits, and more unsolicited outreach from people encouraging you to switch plans. Some of those callers work for ethical agents who genuinely believe a different plan might help you. Others are simply generating commissions.

The question to ask about any plan someone is recommending is specific: does this plan coordinate both my Medicare and Medicaid benefits, or does it only cover the Medicare side? A plan that enrolls you for the Medicare benefits without taking on responsibility for Medicaid coordination is not an upgrade from a truly integrated plan, even if its marketing materials sound similar.

If you feel pressured to switch, you are not obligated to make a decision on the spot. Tell the caller you will think about it and call back. Then contact your State Health Insurance Assistance Program for free, unbiased guidance before making any change.

Your Medicaid Rights and the New Paperwork

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Federal law passed in 2025, sometimes called the One Big Beautiful Bill Act or OBBBA, added new requirements to Medicaid in an attempt to reduce program costs. One of those requirements is a work or community activity requirement for some Medicaid recipients.

If you are 65 or older, or if you receive Medicare because of a disability, you are exempt from these work requirements. You do not need to document hours of employment or community service to keep your Medicaid coverage. This exemption is important and covers the large majority of dual eligible beneficiaries.

What has changed for many dual eligible individuals is not the work requirement itself but the verification and renewal processes that states are building around it. States are implementing more frequent eligibility checks, requiring more documentation to confirm ongoing eligibility, and in some cases sending renewal paperwork to addresses that are outdated. People who do not respond in time to these notices can lose Medicaid coverage even when they remain fully eligible.

If you receive a letter from your state Medicaid office asking you to verify your eligibility or renew your coverage, respond promptly. If you are unsure what the letter is asking you to do, or if you believe you responded and still received a termination notice, contact your state Medicaid office directly. You also have the right to request a fair hearing if you believe your coverage was terminated in error. Legal aid organizations in most states provide free help with Medicaid appeals for people who qualify, and your local Area Agency on Aging can help you find those resources.

If Your D-SNP Plan Exits

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Plan exits affect dual eligible beneficiaries in the same way they affect other Medicare Advantage members, but the stakes are higher because the coordination of two programs is at risk. If your D-SNP leaves your area, you will receive notice from CMS and from your plan. You will have a Special Enrollment Period to choose a new plan.

When evaluating alternatives, the first question is whether another D-SNP or FIDE SNP operates in your area. If one does, compare the integration model carefully before switching. Ask the plan how it coordinates Medicare and Medicaid services, whether it has a care coordinator assigned to dual eligible members, and what services it covers beyond standard Medicare.

If no D-SNP is available and you return to Original Medicare, your Medicaid coverage continues separately through your state. You will need to navigate the two programs independently rather than through a coordinating plan, which requires more active management on your part.

For people who meet the eligibility criteria, Programs of All-Inclusive Care for the Elderly, known as PACE, offer a different model entirely. PACE programs provide comprehensive care through a dedicated care center, covering medical, social, and long-term services under one roof for people who need nursing-home-level care but want to remain in the community. PACE is not available in every area, but where it exists it is worth asking about. Your State Health Insurance Assistance Program or local Area Agency on Aging can tell you whether PACE operates near you.

The central lesson for dual eligible beneficiaries in this policy environment is that not all plans that accept both Medicare and Medicaid actually integrate them well. A D-SNP card does not guarantee coordinated care. The quality of coordination depends on the specific plan, and the only way to evaluate it is to ask specific questions about how care is actually managed across both programs.

Related Reading

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MCR-09_03 Dual Eligible Integration: The FIDE/HIDE/AIP Landscape in 2025 to 2027 MCR-03_01 The One Big Beautiful Bill: What It Does to Medicare and Medicaid