5 Dual-Eligible Trends Every Agent Should Know

People who qualify for both Medicare and Medicaid—commonly called dual-eligible beneficiaries—represent one of the most complex populations Medicare agents serve.

A new KFF analysis examines enrollment, healthcare spending, and chronic-condition data for dual-eligible individuals. The findings show why agents working with this population must look beyond premiums and supplemental benefits when evaluating coverage.

Here are five takeaways from the report—and what they mean for Medicare agents.

1. Dual-eligible beneficiaries represent a significant portion of Medicare

Dual-eligible individuals account for approximately:

• 21% of the total Medicare population
• 13% of the total Medicaid population

The percentage varies considerably by state. Dual-eligible individuals represent at least 30% of Medicare beneficiaries in the District of Columbia, New York, Connecticut, and Louisiana, compared with 11% in Utah.

What this means for agents

Dual eligibility is not a small or isolated part of the Medicare market. Depending on an agent’s service area, a substantial percentage of prospects may receive some level of Medicaid assistance.

Agents should be prepared to ask appropriate questions about:

• Medicaid eligibility
• Medicare Savings Programs
• Part D Extra Help
• Current plan type
• Eligibility for a Dual Eligible Special Needs Plan

PSM’s article on Medicaid program integrity provides additional guidance on Medicaid renewals, eligibility notices, Extra Help, Medicare Savings Programs, and D-SNP eligibility.

2. Dual-eligible beneficiaries account for disproportionate spending

KFF found that dual-eligible individuals represented 15% of traditional Medicare enrollment but accounted for 29% of traditional Medicare spending.

They also represented 13% of Medicaid enrollment but accounted for 30% of combined federal and state Medicaid spending.

What this means for agents

Higher spending often reflects more complex medical and support needs.

A low premium or large supplemental-benefit allowance should not be the deciding factor in a recommendation. Agents must evaluate whether a plan can support the client’s complete healthcare situation, including:

• Physicians and specialists
• Hospitals and care facilities
• Prescription drugs
• Durable medical equipment
• Transportation needs
• Care coordination
• Long-term services and supports
• Medicaid cost-sharing protections

This makes a thorough needs assessment especially important when working with dual-eligible clients.

3. Full-benefit duals have substantially higher per-person costs

Average traditional Medicare spending per person was:

• $24,811 for full-benefit dual-eligible individuals
• $19,950 for partial-benefit dual-eligible individuals
• $10,413 for Medicare beneficiaries without Medicaid

KFF notes that the higher spending among full-benefit duals reflects greater use of medical care and higher rates of chronic conditions.

What this means for agents

Agents should understand the difference between full and partial Medicaid benefits.

A beneficiary may receive full Medicaid benefits, or they may qualify for limited assistance through a Medicare Savings Program. Their eligibility level can affect:

• Medicare premiums
• Deductibles and cost sharing
• Prescription drug assistance
• D-SNP eligibility
• Access to Medicaid-covered services

Qualifying for Medicaid or a Medicare Savings Program can also result in automatic eligibility for the Part D Extra Help program.

Agents should verify the client’s current eligibility instead of assuming that every Medicaid beneficiary receives the same assistance.

4. Dual-eligible beneficiaries have more chronic conditions

KFF found that:

• 57% of full-benefit duals had five or more chronic conditions.
• 56% of partial-benefit duals had five or more chronic conditions.
• 47% of other Medicare beneficiaries had five or more chronic conditions.

These conditions may include diabetes, heart disease, chronic kidney disease, COPD, behavioral health conditions, and other ongoing healthcare needs.

What this means for agents

A plan comparison should account for the full pattern of care—not just the client’s primary physician.

For dual-eligible clients, agents should carefully review:

• Every specialist
• Preferred hospitals
• Current medications
• Pharmacy access
• Prior authorization requirements
• Referral requirements
• Care-management programs
• Transportation benefits
• Relevant supplemental benefits

Agents should also avoid common assumptions about how Medicare coordinates with other programs. For example, veterans may have both Medicare and VA health benefits, but those programs generally operate separately. PSM’s guide to how VA benefits work with Medicare explains several important coordination issues.

5. Spending rises sharply as chronic conditions increase

Among full-benefit dual-eligible individuals with traditional Medicare, average spending increased dramatically with the number of chronic conditions.

For beneficiaries with no chronic conditions, average spending was:

• $3,955 through traditional Medicare
• $4,751 through Medicaid

For beneficiaries with five or more chronic conditions, average spending increased to:

• $40,341 through traditional Medicare
• $27,681 through Medicaid

That is more than 10 times the Medicare spending and nearly six times the Medicaid spending.

What this means for agents

The findings reinforce the importance of plan stability and continuity of care.

Switching a medically complex client into a plan without carefully verifying providers, prescriptions, authorizations, and cost-sharing rules could create serious disruptions.

Agents should document their research and explain that:

• Benefits can change annually.
• Provider participation can change.
• Formulary placement can change.
• Medicaid eligibility can change.
• A D-SNP may require a specific level of Medicaid eligibility.
• The plan with the most advertised benefits is not automatically the most appropriate plan.

PSM’s article on common Medicare misconceptions can help agents address several misunderstandings that arise during these conversations.

Practical Steps for Medicare Agents

The KFF findings suggest several practical ways agents can improve their approach to dual-eligible clients.

Confirm eligibility

Determine whether the client has full Medicaid, partial Medicaid through a Medicare Savings Program, or Part D Extra Help only.

Review the entire care network

Check primary care physicians, specialists, hospitals, pharmacies, medications, equipment suppliers, and other frequently used services.

Evaluate more than supplemental benefits

Food, transportation, OTC, dental, vision, and utility benefits may provide value, but they should not overshadow provider access, prescription coverage, cost sharing, and care coordination.

Watch for eligibility changes

Encourage clients to respond promptly to Medicaid renewal notices and requests for documentation. Losing Medicaid eligibility could affect their cost sharing, Extra Help status, D-SNP eligibility, and enrollment options.

Conduct annual reviews

Use the PSM AEP Preparation Guide to prepare for annual plan changes and build a more organized client-review process.

The Bottom Line

KFF’s analysis confirms that dual-eligible beneficiaries frequently have more chronic conditions, use more healthcare services, and require more coordination than other Medicare beneficiaries.

For insurance agents, this means D-SNP conversations cannot focus exclusively on attractive benefits.

The strongest agents will:

• Verify the client’s eligibility level.
• Review the complete provider and prescription picture.
• Understand how Medicare and Medicaid responsibilities differ.
• Explain plan rules clearly.
• Reevaluate coverage as health needs and eligibility change.

Dual-eligible clients often need more than a plan comparison. They need an agent who understands the complexity of their coverage and can help them make a careful, informed decision.

Related: An Agent's Guide to DSNP Plans

Source

KFF. “Five Key Facts About Spending and Enrollment for People with Medicare and Medicaid—Dual-Eligible Individuals.” Published July 15, 2026.

KFF’s analysis uses linked Medicare and Medicaid administrative and claims data from 2022 and 2023.