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.
Dual-eligible individuals account for approximately:
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.
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:
PSM’s article on Medicaid program integrity provides additional guidance on Medicaid renewals, eligibility notices, Extra Help, Medicare Savings Programs, and D-SNP eligibility.
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.
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:
This makes a thorough needs assessment especially important when working with dual-eligible clients.
Average traditional Medicare spending per person was:
KFF notes that the higher spending among full-benefit duals reflects greater use of medical care and higher rates of chronic conditions.
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:
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.
KFF found that:
These conditions may include diabetes, heart disease, chronic kidney disease, COPD, behavioral health conditions, and other ongoing healthcare needs.
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:
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.
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:
For beneficiaries with five or more chronic conditions, average spending increased to:
That is more than 10 times the Medicare spending and nearly six times the Medicaid spending.
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:
PSM’s article on common Medicare misconceptions can help agents address several misunderstandings that arise during these conversations.
The KFF findings suggest several practical ways agents can improve their approach to dual-eligible clients.
Determine whether the client has full Medicaid, partial Medicaid through a Medicare Savings Program, or Part D Extra Help only.
Check primary care physicians, specialists, hospitals, pharmacies, medications, equipment suppliers, and other frequently used services.
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.
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.
Use the PSM AEP Preparation Guide to prepare for annual plan changes and build a more organized client-review process.
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:
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
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.