Dual Eligible Medicare Advantage (Part C): What You Need to Know (2025)

Once you’ve got both Medicare and Medicaid, you don’t have to stop looking for benefits. Many Medicare Advantage plans add even more support for dual-eligible people.

If you have dual eligibility – meaning you’re eligible for both Medicare and Medicaid at once – then you may prefer the benefits of a Medicare Advantage plan (also known as Medicare Part C).

What Are Dual-Eligible Medicare Advantage Plans?

Medicare Advantage (Medicare Part C) is an alternative way to receive your Medicare health benefits.

Extremely popular throughout the country, these plans typically combine your hospital, doctor and prescription drug benefits into a single health insurance policy. You will recognize these plans by the combination of letters around their names: think HMO, PPO, and RPPO. Tens of millions of people, including those without Medicaid, are enrolled in these plans.

Some Medicare Advantage plans are specifically designed to work hand in hand with Medicaid. Therefore, these plans are called dual-eligible Medicare Advantage plans.

Here are five reasons you might want a dual-eligible Medicare Advantage plan of your own.

More Doctor Choices Compared to Medicaid

If you want to use your Medicaid coverage with Medicare, then you’ll have to find doctors who accept Medicaid payment. And if you see doctors who take Medicare but not Medicaid, then you’ll have to pay the full deductibles and coinsurance under the terms of Original Medicare (Part A and Part B), unless you’re also enrolled in the Qualified Medicare Beneficiary (QMB) program, in which Medicaid funds are used to cover some of your Medicare premiums and cost-sharing (doctors who accept Medicare can’t balance bill QMB patients, even if the doctor doesn’t accept Medicaid).

Paying non-Medicaid doctors could immediately empty your pocket. For that reason, many people on Medicaid choose to replace their Medicare + Medicaid hassle with a dual-eligible Medicare Advantage plan.

With a Part C plan, you’ll have access to doctors who work with a Medicare Advantage company – even doctors who don’t accept Medicaid payment.

When visiting those Medicare Advantage professionals, you’ll only have to pay what Medicare Advantage asks you to pay for care (typically a small copayment for routine outpatient care, but your out-of-pocket costs will tend to be higher if you need surgery or inpatient care). And unlike Original Medicare, you will have the safety of an out-of-pocket spending limit each year.

In other words, you’ll be able to see doctors who accept a certain insurance company. This is a very attractive option if you want to see certain doctors who do not take Medicaid. Medicare Advantage plans are run by health insurers with experience creating adequate doctor networks.

Extra Benefits Available for Dual Eligible Beneficiaries

Combining Medicaid with a Medicare Advantage plan gives you fringe benefits that Medicaid and Medicare do not provide. Depending on the plan you choose, you could receive:

• Vision care, like eye exams and discounts on eyeglasses or contact lenses
• Dental benefits, like routine cleanings
• Discounts on hearing aids
• Free gym memberships
• Transportation to and from doctors’ appointments

New Medicare Advantage rules continue to expand the range of benefits that dual-eligible Part C plans can offer.

Dual-Eligible Special Needs Plans Can Target Chronic Illnesses

You might have read the common term dual-eligible special needs plan (D-SNP or DSNP) by now. What makes this type of Medicare Advantage plan so special?

“Dual” means the plan is only available to people who have both Medicare and Medicaid, meaning dual-eligibles.

“Special needs” means that the plan is designed to address the health care needs of a specific population. Some special needs plans are designed for patients who have certain chronic conditions, such as heart disease or diabetes. But being dual-eligible for Medicare and Medicaid is the only criteria you have to meet in order to qualify for a D-SNP, if one is available in your area.

People who are eligible for both Medicare and Medicaid often have more complex medical needs, and Medicare Advantage dual-eligible special needs plans are designed to address these needs with a managed care approach.

Personalized Help From Insurers and Agents Who Care

If you’re only enrolled in Original Medicare and Medicaid, then you’ll have limited personal help from the government.

But if you enroll in a Medicare Advantage plan, then you’ll have a health insurer to guide you as medical needs arise. The health insurance agent who signed you up for Medicare Advantage can provide personal assistance in getting all the benefits to which you are entitled.

Dual-Eligible Status Gives You Extra Chances to Adjust Your Plan

If you have Medicaid, then your signups for Medicare Advantage are not limited to the Annual Election Period (AEP) at the end of each year. Instead, you’ll have three additional opportunities evenly spaced throughout the year to enroll. Once you compare price quotes online, a licensed agent can set up your policy appropriately.

More opportunities to enroll is an important benefit of your Medicare Advantage dual-eligibility status.

How to Enroll in Dual-Eligible Medicare Part C Plans?

Your dual-eligible Medicare Advantage choices depend on where you live. The ranges of plans vary by state, county and sometimes even by ZIP code. That’s why it’s best to run a broad online search. From there, a qualified and licensed agent will help you compare plans and understand their benefits.

How Costs Are Different for Dual Eligible vs Standard MA Plans

When you qualify for both Medicare and Medicaid, your costs under a Medicare Advantage (MA) plan look very different than those of someone who only has Medicare. Here’s how dual-eligible plans compare to standard MA plans:

• Monthly Premiums
  Many dual-eligible plans come with no monthly premium because Medicaid often covers your Part B premium and sometimes the MA premium itself. Standard MA plans may also advertise $0 premiums, but in those cases you’re still responsible for paying your Part B premium out of pocket.

• Deductibles, Copays, and Coinsurance
  Dual-eligible enrollees frequently pay little or nothing at the point of service. Medicaid helps cover deductibles, copays, and coinsurance. By contrast, people in standard MA plans are responsible for these out-of-pocket amounts, which can add up quickly with frequent doctor visits or hospital stays.

• Out-of-Pocket Maximums
  All Medicare Advantage plans set an annual out-of-pocket maximum. For dual-eligible members, costs rarely reach those limits because Medicaid pays most of the cost-sharing along the way. Standard MA enrollees bear more direct responsibility for costs until they hit their plan’s cap.

• Prescription Drug Coverage
  Most dual-eligible plans include Part D drug coverage, with Medicaid covering or reducing your copays. You may even qualify for the Extra Help program, which lowers prescription costs further. In standard MA plans, you’re subject to the normal Part D cost structure: monthly premiums, deductibles, and copays based on the plan’s formulary.

• Extra Benefits
  Many dual-eligible plans bundle in extra benefits at no added cost. Standard MA plans may also offer these perks, but sometimes with more limits or extra fees.

Next Steps

Choosing the right Medicare Advantage plan is an important decision, especially if you qualify for both Medicare and Medicaid. To make sure you understand all your options, compare available plans in your area and see how the benefits and costs line up with your needs.

Dual-eligible beneficiaries may qualify for a Special Needs Plan, which is designed to coordinate both Medicare and Medicaid benefits. To learn more about how these plans can help, see the benefits of Medicare Advantage Special Needs Plans.

If you’d like personalized guidance, consider speaking with a licensed Medicare agent. They can walk you through your choices, explain how dual-eligible benefits work in your state, and help you enroll in a plan that makes the most sense for your health and budget.