The unique access challenges faced by patients who qualify for both Medicare and Medicaid.

There are approximately 13 million people in the United States who are enrolled in both Medicare and Medicaid simultaneously. They qualify for Medicare by virtue of age or disability. They qualify for Medicaid by virtue of income. In theory, having two programs covering their care should make them among the most protected patients in the system.

In practice, dual eligible beneficiaries face some of the most complex and fragmented access challenges of any patient population. The gap between what they are technically entitled to and what they can actually access is not a small one. It is structural, it is persistent, and it is shaped by the specific way Medicare and Medicaid were designed to interact, which is to say, not very well.

Who dual eligible beneficiaries are

The dual eligible population is not a single, uniform group. It includes elderly adults who spent their working lives in low-wage jobs and aged into both programs. It includes people with significant disabilities who qualified for Medicare through SSDI and for Medicaid through low income. It includes people with end-stage renal disease, serious mental illness, and complex chronic conditions who require intensive, ongoing specialty care.

Nearly 1 in 5 people with Medicare are also enrolled in Medicaid. People in this group have lower incomes, are more racially and ethnically diverse, and often face greater mental and physical health challenges than the general Medicare population.

What they share is this: they are navigating two separate federal programs, administered by separate agencies, with separate eligibility rules, separate benefit structures, separate prior authorization processes, and separate renewal requirements. The programs are designed to work together. The reality is that they frequently do not.

The coordination problem

Medicare is the primary payer for dual eligible beneficiaries. Medicaid fills in behind it, covering cost-sharing, providing additional benefits, and managing services Medicare does not cover, including long-term services and supports, behavioral health, and transportation.

The theory is that Medicaid acts as a wrap-around, making the combined coverage more comprehensive than either program alone. But Medicare and Medicaid often fail to work properly together, leaving dually eligible individuals with double the delays and a frustrating lack of clarity about how to access help and care.

The coordination failure happens at multiple levels.

Eligibility is not synchronized. Medicare eligibility is stable once established. Most people remain continuously covered while alive. Conversely, Medicaid eligibility is based on income and assets, and most beneficiaries must complete an annual eligibility redetermination. A dual eligible patient whose Medicaid coverage lapses during redetermination does not automatically lose Medicare, but they lose the wrap-around benefits that made their coverage workable. Cost-sharing that Medicaid was covering reverts to the patient. Services Medicaid was paying for become unavailable. The gap opens quietly, often without the patient understanding why their coverage suddenly feels different.

Prior authorization is not unified. A specialty medication may require prior authorization from the Medicare Advantage plan, a separate authorization from the Medicaid managed care plan, or both, depending on which benefit is paying. The criteria are not the same. The timelines are not the same. The appeals processes are not the same. A practice managing a dual eligible patient on a specialty biologic is potentially managing two separate PA workflows simultaneously for the same patient and the same drug.

Networks are not aligned. A dual eligible patient may have a Medicare Advantage plan that covers one set of specialty pharmacies and a Medicaid managed care plan that covers a different set. Finding a pharmacy that is inside both networks is not always possible, and when it is not, the patient faces cost-sharing that neither program will cover because the pharmacy is out of network for at least one of them.

Copay assistance does not work for this population

This is one of the most consequential and least understood access barriers for dual eligible specialty patients.

Commercial copay assistance programs, the manufacturer copay cards and patient support programs that help commercially insured patients afford specialty medications, are not available to patients with government insurance. Federal anti-kickback rules prohibit manufacturers from offering copay assistance to Medicare or Medicaid beneficiaries. A dual eligible patient cannot use a copay card. Full stop.

This means the entire layer of financial access infrastructure that practices rely on for commercially insured specialty patients simply does not exist for this population. The workaround is manufacturer PAP enrollment. But PAP eligibility for dual eligible patients has its own complications.

To be eligible for PAP in 2026, Medicare Part D and Medicare Advantage patients must meet the annual pre-tax household income eligibility requirement of at or below 300 percent of the Federal Poverty Level and must be unable to afford their copayment. For a dual eligible patient, income verification is already built into Medicaid eligibility. But the PAP application still requires documentation, physician signatures, and active enrollment management. And some manufacturers have tightened their PAP criteria in direct response to the IRA's Part D out-of-pocket cap, reasoning that the $2,000 cap reduces the financial burden on Medicare patients enough to narrow PAP eligibility.

Some medicines will no longer be part of PAPs for 2026. Patients with Medicare LIS must submit a copy of their denial letter with their application. The Extra Help program, also called the Low Income Subsidy, covers most dual eligible beneficiaries automatically and dramatically reduces their Part D cost-sharing. But not all dual eligible patients are automatically enrolled in Extra Help, and the ones who are not are the ones most exposed to the full cost-sharing structure.

The D-SNP landscape in 2026

Dual Eligible Special Needs Plans, known as D-SNPs, are Medicare Advantage plans specifically designed for dual eligible beneficiaries. They are meant to coordinate Medicare and Medicaid benefits under one plan, reducing the fragmentation problem described above.

The D-SNP model has been evolving rapidly, and the changes effective in 2026 are significant.

CMS rolled out updates in 2025 that take effect in 2026, aiming to make D-SNPs more integrated and effective. These stem from layered federal rulemaking, including the CY 2026 final rule issued April 4, 2025, and focus on better aligning Medicare and Medicaid.

Health risk assessments now have formally codified timelines. Plans must complete an initial comprehensive assessment within 90 days of enrollment, covering physical health, social factors, and barriers like housing. They need to make at least three real attempts to reach the enrollee on different days and times without relying only on robocalls.

A new monthly special enrollment period now lets full dual eligibles switch to an integrated D-SNP to match their Medicaid plan, replacing the previous quarterly option. This is a meaningful improvement for patients whose Medicare and Medicaid plans were misaligned, which is a common source of network and coordination failures.

CMS ended the Medicare Advantage Value-Based Insurance Design model in 2025. In 2026, many of the nonmedical supports that beneficiaries value continue through Special Supplemental Benefits for the Chronically Ill but with stricter eligibility rules. The practical effect is that some dual eligible patients who relied on supplemental benefits for food, transportation, or utilities are experiencing narrower access to those supports even as their clinical coverage nominally improves.

The integration improvements are real. The gap between what integrated D-SNPs promise and what they deliver operationally is also real. A plan that is required to conduct health risk assessments is not the same as a plan that conducts them well. A monthly enrollment period is not helpful to a patient who does not know it exists.

What happens to specialty access inside this population

The access failures that affect dual eligible specialty patients are not random. They follow predictable patterns rooted in the structure of the programs.

Prior authorizations get lost between the two programs. When a specialty medication falls under Medicare Part B as an administered drug, the Medicare Advantage plan processes the PA. When it falls under Part D as a pharmacy drug, a different process applies. For a dual eligible patient in a D-SNP that is supposed to coordinate these, the coordination is only as good as the plan's operational execution. Many plans execute it poorly.

Redetermination gaps interrupt treatment. A dual eligible patient who loses Medicaid coverage during annual redetermination loses the wrap-around benefits that covered their cost-sharing. If they are in the middle of a specialty medication course, the financial exposure can be significant and immediate. Practices that are not tracking their patients' Medicaid renewal dates will not see this coming until the patient calls to say they cannot afford their refill.

PAP enrollments that worked for commercially insured patients do not transfer. A practice that has built PAP management infrastructure for its commercial population needs a separate workflow for dual eligible patients: one that screens for Extra Help eligibility, confirms Medicaid coverage status, identifies which manufacturers will accept dual eligible patients into their programs, and manages the documentation requirements specific to government-insured applicants.

Language and literacy barriers compound everything. The dual eligible population includes a disproportionate share of patients with limited English proficiency and limited health literacy. A prior authorization process that requires a patient to respond to correspondence from their plan, or a Medicaid redetermination that requires documentation submission by a deadline, fails completely for patients who cannot read the notice or do not understand what is being asked of them.

The state variation problem

Medicaid is a federal-state partnership, which means the benefits available to a dual eligible patient in Alabama are materially different from those available to a patient in California or Massachusetts. States set their own Medicaid benefit structures, their own managed care contracts, and their own D-SNP integration requirements.

Starting in 2025, CMS required Fully Integrated Dual Eligible Special Needs Plans to have exclusively aligned enrollment, meaning the plans could only enroll dual eligible individuals who received their Medicare and Medicaid benefits from the same parent organization. This requirement pushes toward integration. But the quality of that integration varies by state and by plan.

A practice with dual eligible patients in a state that has invested in integrated D-SNP infrastructure is operating in a different environment than a practice in a state that has not. The federal framework sets a floor. It does not set a ceiling. And it does not eliminate the state-level variation in Medicaid benefit design that creates different access realities for patients in different geographies.

What practices need to build for this population

Dual eligible patients require a different operational approach than commercially insured or Medicare-only patients. The practices that serve them well have built workflows that account for the specific failure modes of this population.

Medicaid status tracking alongside Medicare. Knowing a patient is dual eligible is not enough. Knowing when their Medicaid redetermination is due, whether their Medicaid managed care plan is aligned with their Medicare plan, and whether they are enrolled in Extra Help is the information that makes the difference between a patient who stays on treatment and one who falls off because of a coverage gap nobody anticipated.

PA workflows that account for both programs. For a dual eligible patient in a D-SNP, the prior authorization may be a unified process. For a patient in traditional Medicare with a separate Medicaid managed care plan, it may not be. The practice needs to know which structure applies to each patient and build the PA workflow accordingly.

PAP and Extra Help screening at the point of prescribing. Commercial copay cards are unavailable. The financial access pathway runs through PAP programs and Extra Help. Screening for both at the time of prescribing, not after a denial or after the patient reports a cost problem, is the practice that protects treatment continuity.

Proactive outreach around redetermination. Medicaid redetermination is an annual event with a predictable timeline. A practice that flags patients approaching redetermination and confirms their continued Medicaid coverage before the renewal date is a practice that catches coverage lapses before they interrupt treatment.

Navigation support that matches patient capacity. For dual eligible patients with limited English proficiency or limited health literacy, the administrative burden of maintaining coverage and accessing benefits requires active support. Practices that simply hand patients a phone number and tell them to call their plan are not providing access. They are performing it.

The bigger picture

Dual eligible beneficiaries represent the clearest case in the healthcare system of a population where the gap between theoretical entitlement and actual access is wide and structural. They have two programs covering their care. They are among the most difficult patients to keep on specialty treatment.

The 2026 D-SNP integration requirements are a step toward closing that gap at the plan level. They do not close the gap at the practice level. The operational infrastructure that connects a dual eligible patient to the benefits they are entitled to still has to be built by the practices and operators who serve them.

That infrastructure is not optional for practices with meaningful dual eligible populations. It is the difference between patients who reach treatment and patients who do not.

Taylor McKinney · The Access Gap · @theaccessgap