A Medicare Dual Plan covers you under both Medicare and Medicaid at the same time

A Medicare Dual Plan — also called a "dual may be able to access" plan — means you are enrolled in both Medicare (the federal program for people 65 and older) and Medicaid (the state program for people with low income). You do not choose to be dual may be able to access; you become one when you meet the income and asset limits for Medicaid while already on Medicare. Once you may have access to, you can join a special plan that coordinates coverage between the two programs so you are not paying twice or falling through gaps.

The main reason dual plans exist is to reduce your out-of-pocket costs. Medicare alone leaves you responsible for deductibles, copays, and coinsurance. Medicaid fills in many of those gaps — it often covers what Medicare does not, or covers it with no copay. A dual plan bundles this coordination into one enrollment, so one insurance company manages both programs on your behalf.

Key Takeaways

  • You may have access to for a dual plan only if you meet both Medicare age or disability rules and your state's Medicaid income and asset limits, which vary by state.
  • Dual plans are offered by private insurance companies under contract with both Medicare and your state Medicaid program, not by Medicare or Medicaid directly.
  • Medicaid covers many of Medicare's out-of-pocket costs — deductibles, copays, and coinsurance — so your total costs are usually much lower than Medicare alone.
  • You must live in the state where the plan operates, and you can only join during the annual enrollment period unless you have a may have access to life event.

How dual plans differ from regular Medicare

If you have Medicare alone, you pay a Part B premium, a Part D premium (if you choose drug coverage), and then copays and deductibles when you use care. Medicaid, if you have it separately, covers some of those costs, but the two programs do not always talk to each other, and you may end up with coverage gaps or confusion about who pays first.

A dual plan puts one insurance company in charge of both. That company knows what Medicare covers and what Medicaid covers, so it can route your claim to the right program and make sure you do not fall into a gap. In most cases, Medicaid pays your Medicare premiums and covers your deductibles and copays. You typically pay little or nothing out of pocket when you see a doctor or fill a prescription, depending on the plan and your state's rules.

The trade-off is that dual plans are managed care plans. That means you usually have to use doctors and hospitals in the plan's network, and you may need prior approval for certain services. If you prefer to see any doctor who accepts Medicare, a dual plan may not be the right choice.

Who can join a dual plan

You must meet three conditions. First, you must be enrolled in Medicare — either because you are 65 or older, or because you have been on Social Security Disability Insurance (SSDI) for 24 months. Second, you must live in a state where the plan operates; not all states offer dual plans, and the plans available vary by state. Third, your income and assets must fall below your state's Medicaid limits.

Medicaid income limits are set by each state and change yearly. Some states use 75% of the federal poverty level; others use 100% or more. In 2024, the federal poverty level for a single person was about $14,600 per year, but your state's actual limit could be higher or lower. You will need to check your state's Medicaid program directly to learn the current limits and whether you may have access to.

Asset limits also vary by state. Most states allow you to own a home and a car without counting them toward the limit, but they do count bank accounts, stocks, and other liquid assets. Some states have no asset limit at all. Your state Medicaid office can tell you the exact rules.

What dual plans cover and what they cost

Dual plans cover everything Medicare covers — hospital stays, doctor visits, lab tests, imaging, rehabilitation, hospice — plus everything your state's Medicaid program covers. In most cases, Medicaid also covers services Medicare does not, such as long-term care in a nursing home, personal care information, and dental or vision care (though the scope of these benefits varies by state).

Your out-of-pocket costs depend on the plan and your state. Many dual plans have zero premium, zero deductible, and zero copay for in-network services. Some plans charge small copays — $1 to $5 per doctor visit or prescription. A few plans charge premiums, though Medicaid usually covers them. You should review the plan's Summary of Benefits and Coverage document to see the exact costs before you join.

Prescription drug coverage is included in most dual plans. You do not need to join a separate Part D plan. Your medications are covered under the dual plan's formulary, which is the list of drugs the plan covers. If your current medication is not on the formulary, you can ask for an exception, or you may need to switch to a similar drug that is covered.

How to find and join a dual plan

Dual plans are offered by private insurance companies — carriers like Humana, UnitedHealthcare, Anthem, and others — under contract with both Medicare and your state Medicaid program. You cannot join directly through Medicare or Medicaid; you must contact the insurance company or work with a broker or counselor.

Start by calling your state Medicaid office to confirm you meet the income and asset limits and to ask which dual plans operate in your area. Your state office can also tell you the enrollment important date and any special rules that explore. You can find your state Medicaid office through the Centers for Medicare & Medicaid Services (CMS) website or by calling 1-800-MEDICARE.

Once you know which plans are available, you can review them on Medicare.gov or by calling the plans directly. Compare the networks, copays, and covered services. If you need help understanding the options, you can contact your State Health Insurance information Program (SHIP), which offers free counseling. You can find your local SHIP by calling 1-800-MEDICARE or visiting the Eldercare Locator at 1-800-677-1116.

You can join a dual plan during the annual Medicare Advantage open enrollment period, which runs from January 1 to March 31 each year. If you have a may have access to life event — such as losing other insurance, moving to a new state, or becoming newly may be able to access for Medicaid — you may be able to join outside this window. Ask your plan or your state Medicaid office whether you may have access to for a special enrollment period.

Common mistakes to avoid with dual plans

One mistake is assuming you are automatically enrolled in a dual plan once you may have access to for Medicaid. You are not. You must actively join a plan during the enrollment period. If you do not join, you remain on regular Medicare and Medicaid, which means you still pay copays and deductibles that Medicaid could have covered.

Another mistake is joining a plan without checking the network. Dual plans are managed care, so you must use in-network doctors and hospitals. If your current doctor is not in the plan's network, you will have to switch or pay out of network. Before you join, call the plan and ask whether your doctors are in the network.

A third mistake is not reviewing the plan's formulary before joining. If you take multiple medications, make sure all of them are covered. If a medication is not on the formulary, ask whether the plan will cover it as an exception, or whether you will need to switch to a different drug.

Finally, do not assume your state's Medicaid rules are the same as another state's. Medicaid is run by each state, so income limits, asset limits, covered services, and copays all vary. Always check your specific state's rules before making decisions.

Frequently Asked Questions

Can I stay on a dual plan if I move to a different state?

No. Dual plans are state-specific because Medicaid is run by each state. If you move, you must join a new plan in your new state. Contact your new state's Medicaid office and your local SHIP to learn which dual plans are available and how to join. You may be able to switch plans outside the normal enrollment period if you move.

What happens to my dual plan coverage if my income goes above the Medicaid limit?

You will lose Medicaid coverage, which means you will no longer be may be able to access for the dual plan. You can stay on regular Medicare, but you will need to find other coverage for the gaps — such as a Medigap policy or a Medicare Advantage plan. Contact your state Medicaid office and your plan to understand the timeline and your options.

Do I have to use doctors in the plan's network?

Yes, in most cases. Dual plans are managed care plans, so you typically must use in-network providers to get the full benefit. If you see an out-of-network doctor, you may have to pay the full cost yourself. Some plans allow emergency or urgent care outside the network, but you should check your plan's rules.

Can I have both a dual plan and a Medigap policy?

No. If you are on a dual plan, you do not need a Medigap policy because Medicaid already covers most of your out-of-pocket costs. Having both would be redundant and is not allowed. If you leave the dual plan, you can then join a Medigap policy.

How do I know if a dual plan is better than staying on Medicare and Medicaid separately?

In most cases, a dual plan saves you money because it coordinates coverage and eliminates gaps. However, if you have a doctor who is not in any dual plan's network, or if you prefer the flexibility of seeing any doctor who accepts Medicare, a dual plan may not be right for you. Talk to your SHIP counselor to compare your options.