A Comprehensive Analysis for Dual-Eligible Beneficiaries: Evaluating the Necessity of Medicare Supplement Insurance (Medigap) When Covered by Medicaid

Introduction: Navigating the Intersection of Medicare and Medicaid

For the vast majority of individuals who have health coverage through both Medicare and Medicaid, the purchase of a private Medicare Supplement Insurance policy, commonly known as Medigap, is financially redundant and unnecessary. The fundamental reason for this is that Medicaid, in its role as a comprehensive safety net for low-income individuals, is designed to cover the very same out-of-pocket costs—such as deductibles and coinsurance—that a Medigap policy is sold to address. Paying a monthly premium to a private insurance company for a Medigap policy effectively means paying for a benefit that is already provided through a public program.

This report serves as a detailed guide to understanding the complex interplay between these distinct forms of health coverage. It aims to demystify the rules and provide clarity for beneficiaries and their caregivers who are navigating this landscape. The analysis will proceed by establishing a foundational understanding of each program’s purpose, explaining how Medicare and Medicaid coordinate benefits for those eligible for both, and exploring the legal and financial implications of this coordination.

Crucially, this report will deconstruct what it means to “have Medicaid,” as the level of assistance can vary significantly. This nuance is central to providing a precise and responsible answer. Finally, the report will analyze a more suitable and increasingly common alternative for this population: Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs), which offer integrated care and enhanced benefits. The ultimate goal is to empower the reader with a comprehensive understanding of their coverage options, enabling them to make a financially sound and well-informed decision about their healthcare.

Section 1: Foundational Concepts – Understanding Your Core Health Coverage

To accurately assess the need for any supplemental insurance, it is essential to first understand the distinct purpose and structure of the primary programs involved: Medicare, Medicaid, and Medigap. Each was created to solve a different problem, and their interaction is a direct result of their unique designs. Grasping their individual functions is the first step in comprehending why purchasing Medigap is an illogical choice for most individuals who also have Medicaid.

1.1. The Medicare Framework: Federal Insurance and Its “Gaps”

Medicare is a federal health insurance program established to provide a baseline of coverage for specific populations, irrespective of their income.¹ It primarily serves individuals aged 65 or older, as well as some younger people with certain disabilities or those with End-Stage Renal Disease (ESRD).² The foundational layer of Medicare is known as Original Medicare, which is composed of two distinct parts.⁴

• Medicare Part A (Hospital Insurance): This part of Medicare covers costs associated with inpatient care. This includes semi-private rooms, meals, and nursing services during a hospital stay; care in a skilled nursing facility (SNF) following a qualifying hospital stay; hospice care for terminal illness; and certain home health care services.⁴ For most beneficiaries, Part A is premium-free, provided they or their spouse have worked and paid Medicare taxes for at least 10 years.⁷
• Medicare Part B (Medical Insurance): This part covers a wide range of medical services and supplies that are medically necessary to treat a health condition. This includes services from doctors and other healthcare providers, outpatient hospital care, durable medical equipment (like walkers or wheelchairs), ambulance services, and many preventive services such as flu shots and cancer screenings.⁴ Unlike Part A, Part B requires a monthly premium, which is typically deducted from Social Security benefits.⁷

The critical feature of the Original Medicare program design is that it is not all-inclusive. It was structured to share costs with the beneficiary, creating predictable out-of-pocket expenses often referred to as “gaps” in coverage. These gaps represent a significant potential financial liability for beneficiaries and are the primary reason supplemental insurance exists. The most prominent gaps in Original Medicare include:

• The Part A Hospital Deductible: This is a substantial deductible that a beneficiary must pay for each “benefit period” when admitted as a hospital inpatient. In 2025, this deductible is $1,676.⁶
• Part A Hospital and SNF Coinsurance: For extended inpatient stays, beneficiaries are responsible for a daily coinsurance. For hospital days 61-90, a daily copayment is required. For days 91 and beyond, beneficiaries tap into a 60-day non-renewable “lifetime reserve,” which has an even higher daily copayment.⁶ Similarly, for skilled nursing facility care, Medicare covers the first 20 days in full, but a daily coinsurance is required for days 21 through 100.⁶
• The Annual Part B Deductible: Before Medicare begins to pay for Part B services each year, the beneficiary must first meet an annual deductible. For 2025, this deductible is $257.⁴
• The Part B Coinsurance: After the annual deductible is met, Medicare Part B generally pays only 80% of the Medicare-approved amount for most covered services. The beneficiary is responsible for the remaining 20% coinsurance, with no annual limit on this out-of-pocket cost.⁶

1.2. The Medicaid Safety Net: A Federal-State Partnership for Low-Income Individuals

In contrast to Medicare, Medicaid is a public assistance program, not an earned benefit. It is a joint venture between the federal government and individual states, designed to provide comprehensive health coverage to millions of low-income Americans across all age groups, including children, pregnant women, adults, seniors, and individuals with disabilities.¹ Because states administer their own Medicaid programs according to federal parameters, eligibility rules and the scope of benefits can vary significantly from one state to another.¹

For individuals who are eligible for both Medicare and Medicaid—a group known as “dual-eligibles”—Medicaid serves as a crucial safety net that provides far more than just help with Medicare’s costs. It offers a robust package of benefits that Medicare does not cover. These often include:

• Long-Term Services and Supports: This is perhaps the most significant benefit. While Medicare’s coverage for nursing home care is strictly limited to a maximum of 100 days of skilled care, Medicaid covers long-term custodial care in a nursing facility for those who qualify.⁷ It also often covers home and community-based services (HCBS) to help individuals remain in their homes.⁷
• Additional Medical Services: Medicaid frequently covers essential services that Original Medicare excludes, such as routine dental care, eyeglasses, and hearing aids.¹⁰
• Transportation: Many state Medicaid programs provide non-emergency medical transportation to and from doctor’s appointments and other medical services.³

This expansive coverage demonstrates that Medicaid’s role for dual-eligible beneficiaries is twofold: it fills in Medicare’s cost-sharing gaps, and it provides a suite of essential health benefits that Medicare itself does not offer.

1.3. Medigap: A Private Insurance Solution for Medicare’s Gaps

Medigap, officially known as Medicare Supplement Insurance, is a product of the private insurance market. It is sold by private companies and is specifically designed to do one thing: “fill the gaps” in Original Medicare.⁴ A Medigap policy works in tandem with Original Medicare; after Medicare pays its approved share for a covered service, the Medigap policy then pays its share, reducing the beneficiary’s out-of-pocket liability for deductibles, coinsurance, and copayments.⁴

To purchase a Medigap policy, a beneficiary must be enrolled in both Medicare Part A and Part B.⁴ In exchange for a monthly premium paid to the private insurance company, the policyholder gains predictability and protection from the potentially high costs associated with Medicare’s gaps.⁸

To simplify comparison and protect consumers, Medigap policies are standardized in most states. They are identified by letters (e.g., Plan A, Plan G), and all plans with the same letter must offer the same set of basic benefits, regardless of the insurance company selling it. The only difference between same-letter plans is the price.⁴

It is essential to understand what Medigap is not. Medigap is not a Medicare Advantage (Part C) plan, which is an alternative way to receive Medicare benefits through a private managed care plan.⁴ Furthermore, Medigap is not a government program; it is private insurance that is regulated by federal and state law.¹⁶ The singular purpose of these policies is to supplement Original Medicare, and their value is derived directly from the existence of Medicare’s cost-sharing gaps. When another program, such as Medicaid, already fills those gaps, the core value proposition of a Medigap policy is eliminated.

Section 2: The Dual-Eligible Beneficiary – How Medicare and Medicaid Work Together

For the approximately 12 to 13 million Americans enrolled in both Medicare and Medicaid, the two programs do not operate in isolation.¹ Instead, they are governed by a strict set of federal rules that dictate how they coordinate to pay for healthcare services. This coordination framework is the primary reason why purchasing a Medigap policy is not only financially unwise for this population but also why it is generally illegal for an agent to sell them one.

2.1. The Coordination of Benefits: Medicare Pays First, Medicaid Pays Last

The foundational principle governing the relationship between the two programs is the “coordination of benefits”.¹⁷ For any healthcare service that is covered by both Medicare and Medicaid, the payment order is unambiguous:

1. Medicare is the Primary Payer: Medicare always pays first. When a dual-eligible beneficiary receives a medical service, the provider must bill Medicare. Medicare processes the claim and pays its share of the approved amount—typically 80% of the cost for Part B services after the deductible is met.¹⁸
2. Medicaid is the Payer of Last Resort: After Medicare has paid its portion, the remaining balance, which includes the beneficiary’s deductibles and coinsurance, is then billed to the state Medicaid program.¹⁸ Medicaid, as the “payer of last resort,” then covers these remaining costs, up to the state’s established payment limit for that service.¹

This payment hierarchy is not optional; it is a matter of federal law. It ensures that the federally funded Medicare program bears the initial cost burden, with the joint federal-state Medicaid program stepping in to cover the remaining liability for its low-income beneficiaries.

2.2. The Financial Redundancy: Why Paying for Medigap is Paying for the Same Benefit Twice

The direct consequence of this payment hierarchy is that it renders Medigap coverage financially redundant. The sole purpose of a Medigap policy is to pay for the out-of-pocket costs left over by Original Medicare.⁶ However, for a dual-eligible individual, Medicaid is already performing this exact function.

Consider a practical example: A dual-eligible beneficiary has a doctor’s appointment that costs $100.

• The beneficiary has already met their annual Part B deductible.
• The provider bills Medicare. Medicare approves the $100 charge and, as the primary payer, pays 80% of it, which is $80.
• This leaves a 20% coinsurance of $20, which would normally be the beneficiary’s responsibility.
• However, because the beneficiary is dual-eligible, the provider then bills the state Medicaid program for the remaining $20.
• Medicaid, as the payer of last resort, pays the $20 (or a portion thereof, up to its payment limit), and the beneficiary owes nothing.

If this same individual were also paying $150 per month for a Medigap policy, that policy’s function would be to pay the same $20. The beneficiary would be paying a significant monthly premium to a private company for a benefit they are already entitled to receive from Medicaid at no cost. This creates a situation of duplicative coverage where the private policy provides no additional value, making it an imprudent use of limited financial resources.⁶

2.3. Federal Prohibitions: The Illegality of Selling Medigap to Medicaid Recipients

Recognizing this inherent financial redundancy and the vulnerability of the low-income population served by Medicaid, federal law explicitly protects these beneficiaries. It is illegal for an insurance agent or company to knowingly sell a Medigap policy to an individual who they know is a recipient of Medicaid.⁴

This prohibition is a critical consumer protection measure. It is designed to prevent predatory sales practices and to shield low-income seniors and individuals with disabilities from being persuaded to purchase expensive private insurance products that offer them no real benefit over the public coverage they already have.¹⁶

There are very limited, specific exceptions to this rule. For instance, an agent can legally sell a policy if the state Medicaid program itself has chosen to pay the Medigap premiums for the beneficiary, though this is an exceedingly rare practice.²⁰ Another exception applies to individuals who are enrolled in certain Medicare Savings Programs that only pay for premiums but not for cost-sharing, a crucial distinction that will be explored in detail in the next section.⁶ However, for the vast majority of individuals with comprehensive Medicaid coverage, this legal prohibition is absolute.

2.4. The Pre-Existing Policy Dilemma: I Had Medigap Before I Got Medicaid

A different situation arises for individuals who purchased a Medigap policy when they only had Medicare and later became eligible for Medicaid due to a change in their financial circumstances. The law does not prohibit a beneficiary from keeping a Medigap policy they already own, provided they continue to pay the monthly premiums.²⁰

However, while it may be legal to keep the policy, it is generally not financially advisable to do so.²⁰ The same logic of financial redundancy applies; the beneficiary would be spending their own money on premiums for coverage that Medicaid now provides.

To address this scenario without penalizing the beneficiary, federal law provides a valuable protection: the right to suspend the Medigap policy. A beneficiary who becomes eligible for Medicaid can notify their Medigap insurance company and request to suspend their policy and its premium payments for a period of up to 24 months.²⁰ This is a critical safety net. If the individual loses their Medicaid eligibility at any point during that two-year period, they have a guaranteed right to reinstate their original Medigap policy without having to go through medical underwriting, which could otherwise lead to denial of coverage or higher premiums due to new health conditions.²⁰ This suspension right allows beneficiaries to take full advantage of their Medicaid benefits without permanently forfeving the private coverage they previously secured.

Section 3: A Granular Analysis – The Spectrum of “Having Medicaid”

The statement “I have Medicaid” can mean different things, especially for a Medicare beneficiary. The assistance provided by state Medicaid programs to Medicare recipients is not a single, uniform benefit. Instead, it exists on a spectrum, ranging from comprehensive health coverage to more limited assistance with specific Medicare costs. Understanding where an individual falls on this spectrum is the key to providing the most precise answer to the question of needing Medigap. This nuance is primarily captured by the distinction between “full” and “partial” dual eligibility, which is determined by one’s qualification for various Medicare Savings Programs (MSPs).

3.1. Full vs. Partial Dual Eligibility: A Critical Distinction

The dual-eligible population is broadly categorized into two main groups based on the level of Medicaid benefits they receive.¹⁰

• Full-Benefit Dual-Eligibles (Full Duals): These individuals are enrolled in Medicare and also qualify for the full scope of benefits offered by their state’s Medicaid program. This includes not only assistance with Medicare’s costs but also coverage for services like long-term care, dental, and vision.¹⁰ For this group, the conclusion is unequivocal: Medigap is entirely unnecessary and provides no additional value.
• Partial-Benefit Dual-Eligibles (Partial Duals): This group consists of Medicare beneficiaries who do not qualify for full Medicaid but, due to their limited income and resources, are eligible for help with their Medicare out-of-pocket costs through a Medicare Savings Program.¹⁹ They do not receive the broader health benefits of the state’s Medicaid plan. The level of assistance they get is determined entirely by which MSP they qualify for, making a detailed look at these programs essential.

3.2. The Qualified Medicare Beneficiary (QMB) Program: The “Gold Standard” of Assistance

The Qualified Medicare Beneficiary (QMB) program provides the most comprehensive level of assistance among the MSPs.²³ Individuals who qualify for QMB receive help from their state Medicaid program to pay for nearly all of their Medicare-related costs. The benefits of the QMB program include payment of:

• Medicare Part A premiums (for those who are required to pay them).
• The monthly Medicare Part B premium.
• All Medicare deductibles (both Part A and Part B).
• All Medicare coinsurance and copayments.¹⁸

Because the QMB program covers all of Medicare’s cost-sharing, it effectively functions as a free, comprehensive Medigap policy.²⁵ Therefore, for any individual enrolled in the QMB program, purchasing a Medigap policy is completely redundant and a waste of money.⁶ Furthermore, federal law provides a critical protection for this group: healthcare providers are legally prohibited from billing a QMB-enrolled individual for any Medicare deductibles or coinsurance.¹⁸ This “no billing” rule solidifies the QMB program’s role as a complete replacement for private supplemental insurance.

3.3. SLMB, QI, and QDWI: The Limited-Benefit Programs

Other Medicare Savings Programs offer more targeted, less comprehensive assistance.

• Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI): These two programs are more limited in scope. For individuals who qualify for either SLMB or QI, the state Medicaid program will pay for their monthly Medicare Part B premium, but nothing more.²³ They do not receive assistance with Medicare deductibles, coinsurance, or copayments.

This creates a theoretical “gap” where a Medigap policy could provide a benefit. An individual in the SLMB or QI program could still face out-of-pocket costs from the Part A and B deductibles and the 20% Part B coinsurance. This is the only scenario in which a Medigap policy might seem logical.

However, a simple cost-benefit analysis reveals the financial flaw in this logic for most individuals. Medigap policies carry significant monthly premiums, often ranging from $100 to over $300, depending on the plan, location, and applicant’s age.⁸ The income limits to qualify for SLMB and QI are set just above the federal poverty level.¹¹ It is highly improbable that a person with such limited income could comfortably afford a high monthly Medigap premium. In many cases, the annual cost of the Medigap premiums could easily exceed the very out-of-pocket costs the policy is intended to cover, making it a poor financial decision.⁶

• Qualified Disabled & Working Individual (QDWI): This is a more specialized program designed for certain individuals with disabilities who have returned to work and lost their premium-free Medicare Part A. The QDWI program helps by paying their monthly Part A premium, but it does not cover any other cost-sharing.²³ The same financial logic applies here as with SLMB and QI.

The table below provides a clear, at-a-glance summary of the different Medicare Savings Programs, their benefits, and the general federal income and resource limits for 2025. It is important to note that some states may have higher limits or may not count certain assets, so it is always advisable to apply even if one’s income appears to be slightly over the limit.²⁴

Program Name	What Medicaid Covers for the Beneficiary	2025 Monthly Income Limit (Individual)	2025 Monthly Income Limit (Couple)	2025 Resource Limit (Individual)	2025 Resource Limit (Couple)
Qualified Medicare Beneficiary (QMB)	Part A & B Premiums, Deductibles, Coinsurance, and Copayments	$1,325	$1,783	$9,660	$14,470
Specified Low-Income Medicare Beneficiary (SLMB)	Part B Premium Only	$1,585	$2,135	$9,660	$14,470
Qualifying Individual (QI)	Part B Premium Only	$1,781	$2,400	$9,660	$14,470
Qualified Disabled & Working Individual (QDWI)	Part A Premium Only	$5,302	$7,135	$4,000	$6,000

Source: ¹¹

Note: Income and resource limits are based on federal guidelines for 2025 and may be higher in Alaska and Hawaii. Some states, like California, have eliminated the asset test for MSPs.27 Limits are subject to annual adjustments.

This tiered structure of support reveals a deliberate policy design. The most comprehensive assistance (QMB) is directed at those with the lowest incomes, at or below the federal poverty level. The less comprehensive, premium-only assistance (SLMB, QI) is for those with slightly higher incomes. This targeted approach allocates limited public funds to alleviate the most predictable financial burdens for the most vulnerable populations. It also leads to the logical question: if Medigap is not a viable solution even for those with limited assistance, what is the right path forward?

Section 4: The Integrated Care Alternative – Dual-Eligible Special Needs Plans (D-SNPs)

For nearly all dual-eligible individuals, regardless of whether they have full Medicaid or are enrolled in a Medicare Savings Program, there is a modern and far more beneficial alternative to the combination of Original Medicare and a Medigap policy. This alternative is a specific type of Medicare Advantage plan known as a Dual-Eligible Special Needs Plan (D-SNP). These plans are designed from the ground up to address the unique needs of this population, moving beyond simply paying bills to offering coordinated care and a wealth of extra benefits.

4.1. An Introduction to D-SNPs: The Modern Solution

D-SNPs are a specialized category of Medicare Advantage (Part C) plans created exclusively for individuals who are enrolled in both Medicare and Medicaid.²⁸ They are offered by private insurance companies that must hold contracts with both the federal Medicare program and the respective state Medicaid agency.²⁹ This dual-contracting requirement is fundamental to their operation.

Unlike the fragmented system where a beneficiary might carry separate cards for Medicare and Medicaid, a D-SNP integrates these benefits into a single, managed plan.²² By law, all D-SNPs must provide, at a minimum, all the benefits covered under Original Medicare Part A and Part B, as well as Medicare Part D for prescription drugs.²² Crucially, they are also required to coordinate the delivery of all Medicare and Medicaid benefits for their members, creating a more seamless healthcare experience.²⁹

4.2. The D-SNP Value Proposition: Beyond Just Paying Bills

The advantages of a D-SNP extend far beyond the cost-coverage functions of Medigap. They represent a paradigm shift toward integrated, managed care, which is particularly beneficial for a population that often has complex health needs and faces significant socioeconomic challenges.³²

• Coordinated Care: A signature feature of most D-SNPs is the provision of a care coordinator or care manager.³⁰ This is a designated individual who can help a member navigate the complexities of their health plan, understand their benefits, find specialists, schedule appointments, and manage chronic conditions.²² This level of support helps to address the fragmented and inefficient care that can result from the separate administration of Medicare and Medicaid.³²
• Enhanced Benefits: Perhaps the most tangible advantage for members is the rich array of supplemental benefits that D-SNPs typically offer at no additional cost. These are benefits not covered by Original Medicare or Medigap policies and can represent significant value. Common extra benefits include:

• Comprehensive dental coverage (including cleanings, fillings, and sometimes dentures).
• Vision care (exams and allowances for eyeglasses).
• Hearing services (exams and allowances for hearing aids).
• Transportation to and from medical appointments.
• Credits for over-the-counter (OTC) health products and healthy foods.
• Fitness program memberships (e.g., SilverSneakers).²²
• Low or No Cost: For the vast majority of dual-eligible beneficiaries, D-SNPs come with a $0 monthly premium.²² The member’s Medicaid or MSP benefit continues to cover their Medicare Part B premium. Furthermore, D-SNPs are structured to have minimal or no copayments, coinsurance, or deductibles for covered services, effectively eliminating out-of-pocket costs for the member.

4.3. Key Considerations for Evaluating a D-SNP

While D-SNPs offer compelling advantages, they operate as managed care plans, which involves certain trade-offs and considerations.

• Provider Networks: The most significant difference from Original Medicare is the use of provider networks. To receive care at the lowest cost, members of a D-SNP must generally use doctors, hospitals, and specialists that are in the plan’s network.⁴ Before enrolling, it is imperative for a beneficiary to verify that their current and preferred healthcare providers are part of the D-SNP’s network.
• Drug Formularies: Each D-SNP has its own prescription drug formulary, which is a list of covered medications. While these formularies are generally comprehensive, a beneficiary must confirm that their specific prescriptions are included and what, if any, cost-sharing might apply.²⁹
• Plan Availability and Integration Level: D-SNPs are widespread, available in 46 states, but their availability can vary by county or zip code.²⁹ Furthermore, D-SNPs have different levels of integration with the state Medicaid program, categorized as Fully Integrated (FIDE), Highly Integrated (HIDE), or Coordination-Only (CO).²⁹ Plans with higher levels of integration (FIDE and HIDE) generally offer a more seamless experience and better coordination of all benefits.

Individuals considering this path should use the official Medicare Plan Finder tool on Medicare.gov to see which D-SNPs are available in their area. For personalized, unbiased guidance, contacting the local State Health Insurance Assistance Program (SHIP) is highly recommended. SHIP counselors can provide one-on-one assistance in comparing plans and understanding the enrollment process.²⁹

The following table provides a high-level comparison of the three primary coverage pathways available to a dual-eligible beneficiary, starkly illustrating the advantages and disadvantages of each approach.

Coverage Pathway	Monthly Premiums (Beneficiary Cost)	Out-of-Pocket Costs (Deductibles, Coinsurance)	Provider Choice	Care Coordination	Supplemental Benefits (Dental, Vision, Hearing)	Prescription Drug Coverage
1. Original Medicare + Full Medicaid/QMB	$0 (Medicaid/MSP pays Part B premium)	$0 (Medicaid/QMB pays all cost-sharing)	Broad (Any doctor/hospital that accepts Medicare)	None (Fragmented system)	Varies by state Medicaid program	Covered by separate Part D plan (with Extra Help)
2. Original Medicare + SLMB/QI + Medigap	High (Beneficiary pays Medigap premium, which can be $150+)	Minimal to none (Medigap covers most cost-sharing)	Broad (Any doctor/hospital that accepts Medicare)	None	None	Covered by separate Part D plan (with Extra Help)
3. Dual-Eligible Special Needs Plan (D-SNP)	$0 for most plans	$0 for most services	Limited (Must use plan’s network of providers)	High (Typically includes a dedicated care coordinator)	High (Typically includes comprehensive dental, vision, hearing, etc.)	Included (Integrated Part D coverage)

Source: Synthesized from ⁴

This comparison makes it clear that Pathway 2, which involves purchasing a Medigap policy, is the least advantageous. It imposes a high monthly premium cost on a low-income individual without providing any significant benefit over the other two pathways. For most dual-eligible beneficiaries, the choice is between the broad provider access of Original Medicare (Pathway 1) and the integrated care and rich supplemental benefits of a D-SNP (Pathway 3). Given the added value of care coordination and extra benefits at no additional cost, the D-SNP model is often the most compelling and logical choice.

Conclusion and Final Recommendations

The analysis of the intricate relationship between Medicare, Medicaid, and Medigap leads to a clear and consistent set of conclusions. The necessity of purchasing a private Medicare Supplement Insurance policy is almost entirely negated when a beneficiary is also covered by Medicaid. The core function of Medigap—to pay for Medicare’s out-of-pocket costs—is rendered obsolete by Medicaid’s role as the secondary payer for dual-eligible individuals. This financial redundancy is so well-established that federal law protects this vulnerable population by making it illegal for agents to knowingly sell them these duplicative policies.

The nuance lies in the spectrum of Medicaid assistance. The level of support a beneficiary receives through their state’s Medicaid program or a Medicare Savings Program directly determines the most appropriate course of action.

Based on this comprehensive analysis, the following tiered recommendations are provided:

• For Individuals with Full Medicaid or the Qualified Medicare Beneficiary (QMB) Program:
  It is definitively recommended that these individuals do not purchase a Medigap policy. It provides no financial benefit and is an unnecessary expense. Medicaid or the QMB program already covers all Medicare premiums, deductibles, and coinsurance, functioning as a superior, cost-free alternative to any private supplement. If a Medigap policy was owned prior to gaining this eligibility, the beneficiary should immediately contact their insurance company to exercise their federal right to suspend the policy for up to 24 months. This preserves the policy in case Medicaid eligibility is lost in the future.
• For Individuals with the Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individual (QI) Program:
  While these individuals receive help only with their Part B premium and may still face Medicare’s other out-of-pocket costs, purchasing a high-premium Medigap policy is highly unlikely to be a cost-effective solution for this low-income population. The monthly cost of the policy would likely outweigh the potential benefits. It is strongly recommended that these individuals investigate the Dual-Eligible Special Needs Plans (D-SNPs) available in their area. Enrolling in a D-SNP will likely eliminate their remaining out-of-pocket costs, provide integrated prescription drug coverage, and offer significant extra benefits, such as comprehensive dental, vision, and hearing care, almost always for a $0 monthly premium.

The Universal Recommendation

Ultimately, every beneficiary’s situation is unique, involving specific health needs, preferred doctors, and prescription drug requirements. Therefore, the single most important piece of advice for any individual navigating these options is to seek personalized, expert guidance. It is universally recommended that beneficiaries contact their State Health Insurance Assistance Program (SHIP). SHIPs provide free, unbiased, and confidential one-on-one counseling. A trained SHIP counselor can review an individual’s specific eligibility, explain the D-SNP plans available in their county, help verify provider networks and drug formularies, and provide the support needed to make the best possible choice for their health and financial well-being. Information to find a local SHIP can be found at shiphelp.org.

Works cited

1. How Does Medicare Medicaid Dual Eligibility Work? – National Council on Aging, accessed August 12, 2025, https://www.ncoa.org/article/what-does-it-mean-to-be-dual-eligible-for-medicare-and-medicaid/
2. Parts of Medicare | Medicare, accessed August 12, 2025, https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare
3. An overview for patients who may qualify for both Medicare and Medicaid, accessed August 12, 2025, https://libtayohcp.com/resources/pdf/understanding-dual-eligible-health-benefits-brochure.pdf
4. Choosing a Medigap Policy – Medicare, accessed August 12, 2025, https://www.medicare.gov/publications/02110-medigap-guide-health-insurance.pdf
5. Get Medigap Basics | Medicare, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/medigap/basics
6. Medigap – Center for Medicare Advocacy, accessed August 12, 2025, https://medicareadvocacy.org/medicare-info/medigap/
7. Dual Eligibility for Medicare and Medicaid: How It Works, accessed August 12, 2025, https://www.medicaidplanningassistance.org/dual-eligibility-medicare-medicaid/
8. Get Medigap Costs | Medicare, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/medigap/basics/costs
9. Eligibility Policy | Medicaid, accessed August 12, 2025, https://www.medicaid.gov/medicaid/eligibility-policy
10. An overview for patients who may qualify for both Medicare and Medicaid, accessed August 12, 2025, https://www.libtayohcp.com/sfsites/c/resource/Libtayo_Surround_Resources_Assets_Part_3/understanding-dual-eligible-health-benefits-brochure.pdf
11. Seniors & Medicare and Medicaid Enrollees | Medicaid, accessed August 12, 2025, https://www.medicaid.gov/medicaid/eligibility/seniors-medicare-and-medicaid-enrollees
12. Find a Medigap policy that works for you – Medicare, accessed August 12, 2025, https://www.medicare.gov/medigap-supplemental-insurance-plans/
13. What’s Medicare Supplement Insurance (Medigap)?, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/medigap
14. Learn How Medigap Works – Medicare, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/medigap/basics/how-medigap-works
15. Medicare Advantage vs. Medicare Supplement plans: What’s the difference? – Humana, accessed August 12, 2025, https://www.humana.com/medicare/medicare-resources/medicare-advantage-vs-medicare-supplement
16. Illegal Medigap practices | Medicare, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/medigap/ready-to-buy/how/illegal-practices
17. How Medicare works with other insurance | Medicare, accessed August 12, 2025, https://www.medicare.gov/health-drug-plans/coordination
18. How Medicaid works with Medicare – Medicare Interactive, accessed August 12, 2025, https://www.medicareinteractive.org/understanding-medicare/cost-saving-programs/medicare-and-medicaid/how-medicaid-works-with-medicare
19. CMS Guidance: Reporting Expectations for Dual-Eligible Beneficiaries, Updated – Medicaid, accessed August 12, 2025, https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-guidance-reporting-expectations-for-dual-eligible-beneficiaries-updated/
20. New York Fully Integrated Duals Advantage (FIDA) Demonstration …, accessed August 12, 2025, https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NYMedigapFAQ.pdf
21. Keep Medigap / Supplement Insurance When on Medicaid?, accessed August 12, 2025, https://www.medicaidlongtermcare.org/benefits/medicare-supplement-insurance/
22. Dual eligible Special Needs plans (D-SNP) | UnitedHealthcare, accessed August 12, 2025, https://www.uhc.com/medicare/shop/dual-special-needs-plans.html
23. LIST AND DEFINITION OF DUAL ELIGIBLES – CMS, accessed August 12, 2025, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicareenrpts/downloads/buy-indefinitions.pdf
24. Medicare Savings Programs | Medicare, accessed August 12, 2025, https://www.medicare.gov/basics/costs/help/medicare-savings-programs
25. Medicare Savings Programs, accessed August 12, 2025, https://medicareadvocacy.org/medicare-info/medicare-savings-programs/
26. Medicare Savings Programs (MSP) | Department of Health Care Policy and Financing, accessed August 12, 2025, https://hcpf.colorado.gov/medicare-savings-programs-msp
27. Medicare-Savings-Programs-in-California – DHCS – CA.gov, accessed August 12, 2025, https://www.dhcs.ca.gov/individuals/Pages/Medicare-Savings-Programs-in-California.aspx
28. www.uhc.com, accessed August 12, 2025, https://www.uhc.com/communityplan/dual-special-needs-plans/what-is-a-dsnp#:~:text=A%20Dual%20Special%20Needs%20plan%2C%20or%20D%2DSNP%20for%20short,Medicaid%20at%20the%20same%20time.)
29. Dual-Eligible Special Needs Plans: Frequently Asked Questions …, accessed August 12, 2025, https://justiceinaging.org/dual-eligible-dsnp-frequently-asked-questions/
30. What Is a D-SNP? Understanding Dual Special Needs Plans | Wellcare, accessed August 12, 2025, https://www.wellcare.com/en/resources/what-is-a-dsnp
31. Dual Special Needs plan (D-SNP) – United Healthcare, accessed August 12, 2025, https://www.uhc.com/communityplan/dual-special-needs-plans/what-is-a-dsnp
32. Integrating Medicare and Medicaid Coverage for Dual Eligibles: Recommendations for Reform – PMC, accessed August 12, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11875113/