Dual-Eligible (Medicare + Medicaid): What You Need to Know

Dvir MoschePosted in Uncategorized last updated on April 14, 2025

What Does Dual-Eligible Mean?

Being dual-eligible means you have both Medicare and Medicaid.

These two programs work together to help cover most or all of your health care costs. 💙

Medicare vs. Medicaid: What’s the Difference?

Let’s keep it simple:

Medicare is health insurance from the federal government, usually for people 65 and older or younger people with disabilities.
Medicaid is health insurance from your state, based on your income and resources.

So, Medicare is age-based (or disability-based), and Medicaid is income-based.

When you qualify for both, you get the best of both worlds.

Why Does Being Dual-Eligible Matter?

Being dual-eligible can help save you a lot of money. 💵

Here’s what it usually means for you:

Lower or no premiums for Medicare plans
Little to no copays for doctor visits, hospital stays, or prescriptions
Extra benefits, like dental, vision, hearing, or transportation
Automatic qualification for Extra Help, which lowers the cost of prescription drugs

📌 Tip: If you’re struggling to pay for health care or medications, it’s worth checking to see if you’re dual-eligible.

Who Qualifies as Dual-Eligible?

Not everyone can get both Medicare and Medicaid.

To be dual-eligible, you need to meet certain income and asset limits. Let’s break it down in plain English. 🧩

Income and Asset Limits

Each state sets its own rules for Medicaid, but here’s a general idea:

Monthly income should be low—usually under $1,300 to $1,600 if you’re single
Assets (like money in the bank) often need to be below $2,000 for an individual

💡 Assets don’t usually include your house or car.

Full vs. Partial Medicaid

There are two types of dual-eligibility:

Full Medicaid: You get all Medicaid benefits on top of Medicare—like nursing home care, help with daily needs, and more.
Partial Medicaid: You get limited help, like help paying for your Medicare premiums and copays, but not full Medicaid services.

Real-Life Examples

Let’s say:

👵 Mary, age 72, lives alone in North Carolina.

She gets $1,200/month from Social Security and has less than $1,500 in savings.

She qualifies for full dual-eligibility.

Her Medicare and Medicaid cover nearly everything, and she pays nothing out of pocket for her prescriptions or doctor visits.

👴 Joe, age 67, lives in South Carolina and gets $1,500/month.

He doesn’t qualify for full Medicaid, but he still gets partial help—his Medicare Part B premium is paid for him, and he gets lower copays.

✅ Even if you think you make too much, it’s worth checking.

Many people qualify and don’t even realize it.

What Are the Benefits of Being Dual-Eligible?

Having both Medicare and Medicaid could save a lot of money on your health care. 💰

Here are some of the biggest benefits:

✅ $0 Premiums for Medicare Part B

Most people on Medicare pay over $170 per month for Part B (that’s the part that covers doctor visits).

But if you’re dual-eligible, Medicaid pays that for you.

That’s money back in your pocket every month.

✅ $0 Copays and Deductibles

With dual-eligibility, you may not have to worry about:

Copays at the doctor
Hospital bills
Deductibles before coverage starts

That means peace of mind knowing you won’t get surprise medical bills. 🏥

✅ Extra Help With Prescriptions

You automatically qualify for Extra Help with your Part D drug plan if you’re dual-eligible. This can mean:

$0 to low-cost prescriptions 💊
No more worrying about the donut hole
Coverage that kicks in right away

📌 Real Tip: Many dual-eligible seniors pay just a few dollars—or nothing—for their medications.

Understanding Full-Benefit vs. Partial-Benefit Duals

Not all dual-eligibles get the same level of help.

There are two types:
👉 Full-benefit duals
👉 Partial-benefit duals

Let’s look at the difference and why it matters.

Feature	Full-Benefit Dual	Partial-Benefit Dual
Medicare Part B Premium Paid?	✅ Yes	✅ Yes
Medicaid Long-Term Care?	✅ Yes	❌ No
Dental, Vision, Hearing?	✅ Often	❌ Rarely
Copays/Deductibles?	✅ Covered	⚠️ Sometimes
D-SNP Eligibility?	✅ All plans	⚠️ Some plans only

🟢 What Full-Benefit Covers

If you’re a full-benefit dual, Medicaid gives you full support along with your Medicare.

That usually includes:

$0 monthly Medicare premiums
No deductibles or copays
Long-term care, like help in a nursing home or at home
Dental, vision, and hearing benefits (in some states)
Transportation to doctor visits 🚌

🟡 What Partial-Benefit Covers

If you’re a partial-benefit dual, you still get help, but it’s more limited.

You may get:

Medicare Part B paid for
Help with deductibles and coinsurance
Lower prescription drug costs through Extra Help

You might not get long-term care, dental, or vision from Medicaid, depending on your state.

⚠️ Why This Difference Matters for Plan Selection

Knowing whether you’re full or partial matters when picking the right Medicare Advantage plan or Part D plan:

Some Dual-Eligible Special Needs Plans (D-SNPs) are only for full-benefit duals.
Other plans may accept partial-benefit duals, but the extra perks might be smaller.

📌 Tip: Always check what kind of Medicaid you have before picking a plan.

Or better yet, talk to a local Medicare expert who can help you match the right plan. 😉

What Is a DSNP (Dual Special Needs Plan)?

A DSNP (pronounced “D-snip”) stands for Dual Special Needs Plan.

It’s a special type of Medicare Advantage plan made just for people who have both Medicare and Medicaid. 🧡

These plans are built to meet your needs—and give you extra help along the way.

🧩 How DSNPs Work With Medicaid

DSNPs coordinate your care.

That means:

Medicare covers your doctors and hospitals
Medicaid picks up what Medicare doesn’t, like copays and deductibles
You get one card and one plan that makes everything easier to manage

It’s like having a team working together to ensure you’re covered and saving money.

🎁 Extra Benefits DSNPs Often Include

Here’s the fun part—many DSNPs come with extra perks that Original Medicare doesn’t offer:

Dental coverage (cleanings, fillings, even dentures!) 🦷
Vision and eyeglasses 👓
Hearing aids 👂
Over-the-counter (OTC) allowance to buy items like pain relief, toothpaste, and vitamins 🛒
Transportation to the doctor or pharmacy 🚗
Fitness memberships like SilverSneakers 🏋️‍♂️

📌 Real-Life Tip: Some plans even give you a monthly grocery card or utility bill help.

These are big savings if you’re on a fixed income!

How DSNP Plans Differ from Regular Medicare Advantage

Not all Medicare Advantage plans are the same.

If you have both Medicare and Medicaid, a DSNP might be a better fit than a regular Medicare Advantage plan.

Here’s why.

🏥 Network and Benefit Differences

Both DSNPs and regular Medicare Advantage plans have provider networks, but DSNPs are made just for dual-eligible folks.

That means:

DSNPs often include more doctors who understand Medicaid
DSNPs come with extra benefits, like dental, vision, and hearing
Some DSNPs even give you transportation or a monthly card for groceries or over-the-counter products

👴 Regular Medicare Advantage plans don’t always include these perks, and they’re not required to work with Medicaid.

🤝 How Medicaid Coordinates with DSNPs

DSNPs are designed to work hand-in-hand with Medicaid.

This means:

Your copays are usually $0
You may get better coordination of care
Medicaid can help cover costs that regular plans wouldn’t

📌 With a DSNP, there’s less guesswork about what’s covered and what’s not.

✅ Why Choosing the Right DSNP Matters

Not every DSNP is the same.

Some:

Work with different networks of doctors and hospitals
Offer more or fewer extra benefits
Only accept full-benefit duals, not partial-benefit duals

👉 That’s why comparing your options and finding a DSNP that fits your needs and your Medicaid level is essential.

🗣 Tip from a local agent: “Many of my clients had no idea they could switch to a DSNP with more benefits—and pay nothing extra. A quick check made a big difference.”

How to Enroll in a Dual-Eligible Plan

If you qualify for both Medicare and Medicaid, getting into the right plan is easier than you think—and it can save you a ton. 💵

Here’s how it works:

1️⃣ Step One: Apply for Medicaid First

Before joining a Dual Special Needs Plan (DSNP), your state needs to approve you for Medicaid.

Call your local Medicaid office
Or apply online through your state’s website
You’ll need info like your income, assets, and medical coverage

📌 Tip: If you already have Medicare, you can still apply for Medicaid at any time.

2️⃣ Step Two: Enroll in a DSNP or Medicare Plan

Once you’re approved for Medicaid, you can:

Join a DSNP that fits your needs
Or switch from your current Medicare Advantage or Part D plan to a better one

You don’t have to wait for Medicare’s Open Enrollment in the fall.

Because you’re dual-eligible, you get a Special Enrollment Period (SEP).

🔄 What’s a Special Enrollment Period?

A SEP means you can make changes to your plan once per quarter for the first three quarters of the year.

Jan–Mar
Apr–Jun
Jul–Sep

After September, you can still make changes during Medicare’s Annual Enrollment Period from October 15 to December 7.

📍 Where to Apply for Medicaid

Here’s where to start based on your state:

South Carolina: https://apply.scdhhs.gov or call (888) 549-0820
North Carolina: https://epass.nc.gov or call (800) 662-7030

🧡 Or visit your local Department of Social Services to get help in person.

Real-Life Examples by State 🏡

Sometimes the best way to understand how dual-eligibility works is by hearing real-life stories.

These examples show how Medicare and Medicaid work together, depending on where you live.

🟦 North Carolina: $0 Plan With Full Benefits

Evelyn, a 70-year-old widow from Fayetteville, NC, lived on just $1,100 monthly in Social Security.

She didn’t know she could get Medicaid in addition to her Medicare.

After applying through ePASS, she qualified for full Medicaid.

Now she’s on a DSNP with $0 premiums, no copays, free dental checkups, and a $150 monthly card to use at Walmart for groceries and over-the-counter items. 🎉

“I used to skip doctor visits because I couldn’t afford the copay.

Now I go whenever I need to.” – Evelyn, NC

🟦 Michigan: Prescription Help With Extra Help 💊

George, 68, from Flint, Michigan, qualified for partial Medicaid.

While he didn’t get full Medicaid benefits, he was still eligible for Extra Help with his prescriptions.

His brand-name meds dropped from $45 to just $4, and he no longer pays a premium for his drug plan.

He enrolled through the Michigan Department of Health and Human Services and now saves over $1,000 per year.

🟥 Ohio: Medicaid Wraparound = Full Coverage

In Columbus, Ohio, Linda was overwhelmed by medical bills after a hospital stay.

She had Medicare but didn’t know she qualified for full Medicaid wraparound coverage.

Now, with the Ohio Medicaid program wrapping around her Medicare, she pays $0 out-of-pocket for her specialists, hospital visits, and prescriptions.

“It felt like a second chance. I finally have peace of mind.” – Linda, OH

🟪 Virginia: Meet Cardinal Care ❤️

In Virginia, Medicaid is called Cardinal Care.

James, a retired truck driver from Roanoke, applied for Cardinal Care after learning he could get help even with a modest pension.

Once approved, James joined a DSNP plan with dental, vision, hearing, and a SilverSneakers gym membership.

He also got a $125 OTC monthly card to help with daily essentials.

📌 Tip for Virginians: You can apply through CommonHelp or call (855) 242-8282.

Common Misconceptions About Dual Eligibility 🧐

There are a lot of myths out there about having both Medicare and Medicaid.

Let’s clear up a few of the biggest ones right now:

❌ “I can’t have both Medicare and Medicaid.”

False!
If you meet the rules for both, you absolutely can have both.

Being dual-eligible means you get extra help most people don’t—like $0 premiums and better benefits.

It’s designed to help seniors on a limited income get the care they deserve.

❌ “I have to pay extra if I enroll in a dual plan.”

Not true!
Most DSNPs cost $0 per month, and you may even get help paying for your medications, copays, and hospital bills.

If you qualify, you could save hundreds or even thousands per year.

📌 Many seniors think “free” means “too good to be true”—but in this case, it is help you’ve earned.

❌ “All dual plans are the same.”

Wrong again.
DSNPs can be very different, depending on:

What benefits they include (like dental or vision)
Which doctors are in the plan
What level of Medicaid you have (full vs. partial)

🗣 Tip: Always compare plans or speak with a trusted local agent who can explain your options.

The right plan could give you more benefits with no extra cost.

Mistakes to Avoid When You’re Dual-Eligible 🚫

Even when you have both Medicare and Medicaid, a few mistakes can cost you money or limit your benefits.

The good news?

They’re easy to avoid once you know what to watch out for.

❌ Enrolling in the Wrong Plan

Not every plan is made for dual-eligible folks. If you enroll in a regular Medicare Advantage plan instead of a DSNP, you might:

Miss out on extra benefits like dental, vision, OTC cards, and transportation
End up with surprise copays
Have less help coordinating care

📌 Tip: Always ask, “Is this plan made for people with both Medicare and Medicaid?”

❌ Not Applying for Extra Help

Even if you already have Medicaid, you should still make sure you’re enrolled in Extra Help (also called the Low-Income Subsidy).

It lowers the cost of your prescription drugs and can save you hundreds per year.

💊 Without Extra Help: You might pay full price for meds.
💊 With Extra Help: You could pay $0 to $4 per prescription—or even nothing at all!

❌ Letting Medicaid Lapse

Some seniors don’t renew their Medicaid on time—or don’t realize it needs to be updated every year in some states. If your Medicaid coverage stops, you could:

Lose access to your DSNP
Be responsible for premiums and copays
Miss out on key services

🗂 Make a reminder: Reapply or renew Medicaid on time every year!

How Caregivers Can Help Dual-Eligible Seniors ❤️

If you’re helping a loved one who has Medicare and Medicaid, you’re already doing something amazing.

🙌 Many dual-eligible seniors rely on family members or trusted friends to ensure they get the care and benefits they deserve.

Here are some ways you can help:

📝 Become an Authorized Representative or Have Power of Attorney

To talk with Medicare, Medicaid, or insurance companies on your loved one’s behalf, you may need to be an:

Authorized representative (for Medicaid applications)
Power of attorney (POA) for legal and medical decisions

📌 Tip: Each state has its process, so check with your local Department of Social Services or Medicaid office to get started.

📂 Help Gather Paperwork and Documents

Applications for Medicaid or DSNP plans often require:

Proof of income (like Social Security statements)
Bank account balances
Copies of insurance cards
Utility bills or proof of address

Seniors may find this overwhelming—you can make the process so much easier by helping organize everything.

🔄 Understand How Benefits Work Together

Many caregivers help with:

Scheduling doctor visits
Calling Medicare or Medicaid with questions
Reviewing plan changes and Extra Help status
Helping with renewal deadlines

Knowing how Medicare and Medicaid coordinate benefits can help avoid unexpected costs or coverage issues. 🧠

“I help my dad track his Medicaid renewal each year and make sure his prescriptions are covered—he calls me his ‘personal secretary,’” – Jenny, caregiver in Virginia 💬

When you support someone who’s dual-eligible, you’re helping them live a healthier, more secure life.

And that’s something truly special. 💙

Why Local Support Matters More Than Ever 📍

Regarding Medicare and Medicaid, where you live makes a big difference.

That’s why it helps to work with someone who really knows your area—not just a call center miles away.

Here’s why local support is so valuable:

🗺️ DSNP Options Vary by ZIP Code

Not every Dual Special Needs Plan (DSNP) is available everywhere.

In fact:

One ZIP code may have 5 DSNPs to choose from
The neighboring ZIP code might only have 2 or 3 options
Some counties have plans with more perks than others

📌 Tip: A local agent can check what’s available in your exact ZIP code—and help you compare.

🏛️ Every State’s Medicaid Program Is Unique

Medicaid isn’t the same in every state.

Each one has its own:

Income and asset limits
Enrollment process
Name (like Cardinal Care in Virginia or Healthy Michigan Plan)

If you’re moving from one state to another, your Medicaid benefits might change completely.

👥 Local Agents Understand the Nuances

Local agents aren’t just reading a script—they know:

Which DSNPs work best for North Carolina and South Carolina seniors
How Michigan’s Extra Help rules apply
What kind of Medicaid wraparound coverage exists in Ohio
Who to call if something goes wrong with your renewal or paperwork

🗣 “I’ve sat down at kitchen tables across South Carolina and helped people switch to better plans that save them money and give them more benefits.” – Local Medicare agent

Whether you’re in Charlotte, NC, Grand Rapids, MI, Columbus, OH, or a small town in South Carolina, having someone local makes everything simpler and more personal. 💬

How Palmetto Mutual Can Help You 🤝

At Palmetto Mutual, we know how confusing Medicare and Medicaid can feel—especially when trying to figure it out alone.

That’s why we’re here to guide you step-by-step through the process.

You don’t have to deal with:

❌ Spam calls from pushy telemarketers
❌ Confusing websites that don’t explain your real options
❌ Plans that don’t actually fit your Medicaid level or local network

✅ We Make It Simple—And Personal

Here’s how we help:

We walk you through every step—from checking your Medicaid status to enrolling in the best DSNP for your ZIP code
We specialize in local plans, including those with Medicaid wraparound coverage
We understand the real-world needs of seniors—from saving on prescriptions to making sure you don’t miss important deadlines
We’re licensed in North and South Carolina and have been helping seniors since 2018

Whether in Florence, SC, Wilmington, NC, or anywhere in between—we’re here for you.

📞 Book Your Free Consultation Today!

We offer free, no-pressure consultations to help you understand your options and get the benefits you deserve.

👉 Call us now or click the button below to schedule your one-on-one visit.

💬 Let’s make sure you’re not leaving money or coverage on the table.