Key Takeaways

• Dual-eligible individuals often face layered confusion due to overlapping Medicare and Medicaid coverage rules, which means your guidance can dramatically improve outcomes.

• Understanding enrollment timelines, plan integration, and cost-sharing protections allows you to deliver more precise, relevant help—and build long-term trust.

Why Dual Eligibles Need You More Than Ever

Dual-eligible beneficiaries—those enrolled in both Medicare and Medicaid—represent one of the most medically and economically vulnerable groups in the healthcare system. In 2025, their numbers are rising, and their needs are intensifying. Yet few understand what their coverage actually includes, how it coordinates, or when key decisions must be made.

That’s where your expertise becomes essential. You’re not just offering plan comparisons—you’re untangling overlapping benefits and ensuring they aren’t left exposed. Dual-eligible clients don’t always ask the right questions, so you must anticipate what they need to know before confusion leads to gaps in care.

Defining Dual Eligibility in 2025

As of 2025, a person is considered dual eligible when they qualify for Medicare (based on age or disability) and also meet state income and asset criteria for Medicaid. These individuals may fall into one of several categories:

• Full duals receive full Medicaid benefits along with Medicare.

• Partial duals qualify for help with Medicare premiums and cost sharing, but not full Medicaid benefits.

The type of dual status significantly affects what costs are covered, what services are available, and which plans are suitable. And since Medicaid is state-run, these rules and benefits vary widely.

The Layered Complexity of Coverage

Here’s why dual eligibles often struggle with understanding their benefits:

• Medicare provides national coverage, while Medicaid varies by state.

• Each has different rules for deductibles, copayments, provider networks, and covered services.

• Most duals are automatically enrolled in Medicare Part A and B—but not all understand what Parts C and D mean, or when and how they apply.

In addition, beneficiaries with full Medicaid may qualify for additional wraparound benefits that reduce or eliminate cost sharing—but only if they stay within state guidelines.

As their agent, it’s on you to bridge these distinctions in plain language.

Understanding the Enrollment Landscape

There are specific enrollment and re-enrollment periods that dual-eligible clients must follow. You’ll want to stay ahead of these:

Medicare Enrollment for Duals

• Initial Enrollment Period (IEP): Starts three months before and ends three months after a client turns 65 or qualifies by disability.

• Medicare Advantage Open Enrollment Period (MA-OEP): January 1 to March 31. Duals may switch Medicare Advantage plans.

• Special Enrollment Period (SEP): Dual-eligible clients typically have a continuous SEP, allowing one change per quarter for the first three quarters of the year.

Medicaid Eligibility Reviews

States are now rechecking Medicaid eligibility more strictly than before, especially after the end of COVID-related continuous coverage policies in 2023 and 2024. Clients must respond promptly to Medicaid redetermination requests, or they risk losing benefits without warning.

What Clients Need to Know—And Often Don’t

Most dual-eligible clients are not aware of how their two programs integrate. As their agent, here’s what you should always clarify:

• Medicare pays first, then Medicaid may cover remaining costs.

• Medicaid can pay for premiums, deductibles, and coinsurance if the client qualifies as full dual eligible.

• Prescription drug coverage is provided through Medicare Part D, but beneficiaries are auto-enrolled into benchmark plans unless they actively choose another.

• Long-term care coverage (like nursing home care) comes from Medicaid—not Medicare.

Even basic facts like these are often unknown to your clients. They may not understand the significance of plan changes, and the result can be lost benefits or increased out-of-pocket expenses.

Common Pitfalls That Cost Clients Coverage

When clients don’t understand how their coverage works, it puts them at risk. You need to watch for these avoidable mistakes:

• Missing Medicaid redeterminations, especially after moving or changing contact info.

• Assuming all providers accept both Medicare and Medicaid, when in fact many do not.

• Not reviewing Part D coverage annually, which may result in higher drug costs or uncovered medications.

• Failing to report changes in income or household composition, which can alter eligibility.

These problems are not just administrative. They directly affect whether a client can afford medications, see a doctor, or remain in long-term care.

How to Present Plan Options Without Overwhelming Clients

When working with dual eligibles, less is often more. They don’t need ten plans to choose from—they need one or two that work. Focus on what matters most:

• Coordination of benefits between Medicare and Medicaid

• Lower out-of-pocket costs for prescriptions and hospital stays

• Access to nearby providers who accept both programs

• Eligibility for extra benefits like dental, vision, or transportation

Use clear, simplified visuals or charts if needed, but always prioritize clarity over detail. Many dual eligibles face cognitive, physical, or language barriers that require an extra layer of patience and empathy.

2025 Policy Changes to Know

This year, the Medicare Part D prescription drug benefit includes a new annual out-of-pocket cap of $2,000. While dual eligibles often qualify for full subsidy (Extra Help), it’s still important to track how this change may interact with their current drug plan and whether it alters how medications are tiered or covered.

Also, several states are introducing integrated care models in 2025 that aim to combine Medicare and Medicaid benefits more efficiently. Depending on your region, you may need to guide clients through transitions into new plan types—or ensure they opt out if it doesn’t fit their needs.

Coordinating With Medicaid Offices

You’re not just helping with Medicare. When dual-eligible clients face Medicaid questions, they’ll turn to you first. Here’s how to stay useful without overstepping:

• Stay current on your state’s Medicaid eligibility rules and renewal processes.

• Remind clients to respond to all Medicaid notices promptly, especially during redetermination windows.

• Clarify that Medicaid decisions come from the state, but help clients understand what information is needed to stay compliant.

If your client loses Medicaid, they may face increased Medicare costs—or get auto-enrolled into a plan they didn’t choose.

Building Long-Term Relationships With Duals

Dual-eligible clients aren’t one-time sales. Their situation often changes year to year. By proactively managing their account, you offer stability they can’t get elsewhere. Ways to build trust include:

• Annual reviews during the first three quarters, thanks to continuous SEP access.

• Clear plan explanations during enrollment and re-enrollment periods.

• Checking in during Medicaid renewals, not just Medicare plan windows.

• Making referrals to social workers or benefit coordinators for housing, food, or utility help.

Your reliability becomes their lifeline—and often extends to their caregivers or adult children.

Why It Pays to Specialize in Dual Eligibles

Many agents avoid this segment because of perceived complexity. But that’s exactly why it presents opportunity. In 2025:

• Over 12 million individuals qualify as dual eligible.

• Most qualify for continuous plan changes under SEP.

• Clients who feel supported rarely switch agents.

With the right support model, dual-eligible clients are not high-risk—they’re high-retention.

Guiding Dual-Eligible Clients Is a Role That Requires Precision and Care

This isn’t about selling a plan. It’s about protecting coverage, clarifying benefits, and staying present when the system doesn’t make sense. When you work with dual-eligible clients, your role as an independent agent becomes more than a transaction—it becomes an essential service.

If you’re ready to serve this segment better, we invite you to sign up on BedrockMD. Our platform helps professionals like you with tools, support, and CRM resources built for complex cases. We’re here to help you turn trust into long-term growth.