Dual eligible and Special Needs Plans

If you have Medicare and Medicaid, you are probably leaving money on the table.

Dual eligibility is the most underclaimed thing in Medicare. There are plans built specifically for people who have both, plans built around a single chronic condition, and state programs that pay your Part B premium outright. Most people who qualify for these have never had them explained.

See If You Qualify Call or Text 970.505.9652

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Reviewing dual eligible coverage options

Started by pharmacists Covered is not the same as affordable. A pharmacist knows the difference.

Medicare Savings Programs

2026 limits, and read the note underneath before you rule yourself out.

These are the 2026 federal figures for monthly income and countable resources. Medicare says plainly that you may still qualify in your state even if your income or resources are higher than these, because states do not all count the same things. Do not disqualify yourself on this table. Colorado runs these programs, and we will help you apply.

Program	Monthly income limit	Resource limit	What it pays
QMB	$1,350 single / $1,824 couple	$9,950 single / $14,910 couple	Part A premiums if you owe them, plus Part B premiums, deductibles, coinsurance and copayments.
SLMB	$1,616 single / $2,184 couple	$9,950 single / $14,910 couple	Your Part B premium. You must have both Part A and Part B.
QI	$1,816 single / $2,455 couple	$9,950 single / $14,910 couple	Your Part B premium. You must have both Part A and Part B.
QDWI	$5,405 single / $7,299 couple	$4,000 single / $6,000 couple	Part A premiums only.

Start here

Yes, you can have Medicare and Medicaid at the same time.

It is called being dually eligible, and roughly twelve million people are. Medicare pays first on Medicare-covered services. Medicaid pays last, filling in behind Medicare and any other insurance, up to the state's payment limit. The practical effect is that between the two programs, most of your cost sharing can be covered, and Medicaid picks up categories Medicare simply does not touch.

Medicare pays first. Medicaid fills in the difference.
Medicaid covers things Medicare does not, most importantly long-term nursing facility care beyond Medicare's 100-day limit, and personal care services.
If you are dually eligible you are automatically enrolled in a Medicare drug plan, which covers your medications instead of Medicaid.
Full dual eligibility also qualifies you for Extra Help automatically. You do not have to apply separately.

D-SNP

A Dual Eligible Special Needs Plan is built for exactly this situation.

A D-SNP is a Medicare Advantage plan that only enrolls people who have both Medicare and Medicaid, and that holds a contract with the state Medicaid agency so the two programs actually coordinate instead of you being the go-between. Every Special Needs Plan is required to include Part D drug coverage, which a regular Advantage plan is not. Many include extra benefits and care coordination aimed at the population they serve.

Enrollment is limited to people who qualify, and you stay enrolled only while you still meet the condition.
All Special Needs Plans must include drug coverage.
The most integrated versions give you one combined appeals and grievance process instead of separate Medicare and Medicaid tracks.
Networks, formularies and referral rules vary by plan. We check yours against your doctors and your medication list before recommending anything.

C-SNP

A Chronic Condition Special Needs Plan is built around one diagnosis.

A C-SNP restricts enrollment to people with one or more severe or disabling chronic conditions, and tailors the network, the drug list and the care coordination around that condition. Medicare regulation lists a broad set of condition categories that a C-SNP may be built around, including diabetes, chronic heart failure, cardiovascular disorders, chronic lung disorders such as COPD and asthma, chronic kidney disease, cancer, dementia and conditions associated with cognitive impairment, autoimmune disorders, chronic and disabling mental health conditions, neurologic disorders, HIV and AIDS, and substance use disorders.

That list is what CMS permits a plan to be built around. It is not a promise that a plan exists for your condition in your county. Available plans vary by area, and we will tell you straight whether one exists near you.
Your condition has to be verified. Either the plan contacts your provider before you enroll, or you complete an assessment your provider confirms before the end of your first month.
If it cannot be verified you will be disenrolled at the end of the second month, so this is not a step to leave hanging.
If you are found ineligible for a C-SNP, that opens a Special Enrollment Period so you are not stranded.

I-SNP

You can qualify for an Institutional plan while still living at home.

Most people assume an Institutional Special Needs Plan is only for nursing home residents. It covers those who reside or are expected to reside 90 days or longer in a facility, but it also covers people who are institutional-equivalent, meaning living in the community while requiring an institutional level of care. That determination uses a state assessment tool plus an assessment by an impartial party. It is one of the least understood options in Medicare and worth asking about if you are caring for someone at home.

Ninety days or longer in a skilled nursing facility, nursing facility, psychiatric or rehabilitation hospital, or long-term care hospital.
Or living at home while needing an institutional level of care, confirmed by assessment.
If you are managing a parent's care at home and it is getting harder, ask us about this specifically.

Extra Help

2026 Extra Help limits, and the tier that no longer exists.

Extra Help pays for your Medicare drug coverage. In 2026 the income limits are $23,940 for an individual and $32,460 for a married couple, with resource limits of $18,090 and $36,100. If you qualify, your drug plan premium and deductible are both zero, generic drugs cost up to $5.10 each and brand names up to $12.65, and once your total drug costs reach $2,100 you pay nothing for covered drugs the rest of the year. One thing worth knowing: the old partial or sliding-scale Extra Help tier was eliminated. Everyone who qualifies now gets the full subsidy.

You get Extra Help automatically if you have full Medicaid, state help paying your Part B premium, or SSI payments.
You will not be charged a Part D late enrollment penalty while you have Extra Help.
If you have QMB, providers are not allowed to bill you for services and items Medicare covers, including deductibles, coinsurance and copays. If you are getting billed anyway, that is worth a phone call to us.

The rules that changed

If you have Medicaid or Extra Help, you can change plans monthly.

Under current rules, people who qualify for Extra Help or Medicaid get a once-per-month opportunity to move into a standalone prescription drug plan. Separately, full-benefit dual eligibles get a monthly opportunity to move into an integrated Dual Eligible Special Needs Plan when they also get Medicaid services through an affiliated plan. These replaced the older quarterly windows. Read the first one carefully though: it moves you into a standalone drug plan, not between Advantage plans, which is a distinction that trips up almost everybody.

Monthly window into a standalone drug plan if you have Extra Help or Medicaid.
Monthly window into an integrated D-SNP if you are a full-benefit dual and the plan aligns with your Medicaid coverage.
Any gain, loss or change in Medicaid or Extra Help status gives you 3 months from the change or the notice, whichever is later.
Because the specifics turn on which category you fall into, this is one to ask about rather than guess at.

If your Medicaid stops

You do not lose your plan the same day you lose Medicaid.

If you are in a Special Needs Plan and you stop meeting the eligibility criteria, but you could reasonably be expected to qualify again within six months, the plan keeps you eligible for a grace period. That period is at least 30 days and no more than 6 months, and the plan itself decides the length. A lot of websites state a flat six months. That is not the rule. Call your plan and ask what yours is, then use your 3-month Special Enrollment Period to sort out the next step.

The grace period is at least 30 days and up to 6 months, set by your plan.
Losing Medicaid opens a 3-month Special Enrollment Period from the loss or the notice, whichever is later.
If you get a letter saying your Medicaid ended, bring it to us that week rather than at the end of the grace period.

What people say

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Why Haven

Why people end up here.

Whether a drug is covered is the easy question. What the plan does with it after that is where the year gets expensive, and that detail is a pharmacist's daily work.

Ask around first

Ask the pharmacist you already see.

Haven was started by the pharmacists at Good Day Pharmacy. So you can check us out before you ever pick up the phone. Not many people in this business can say that.

The fair question

We do not pick plans around pharmacies.

It is fair to wonder. We do not. If the best plan for your medications means filling somewhere else, we will tell you so. The only time a pharmacy comes into it is if you ask us to keep yours.

Read like a pharmacist

Covered is not the same as affordable.

A plan can list your medication and still cost you much more than the plan next to it. It comes down to tiers, limits, and prior authorizations. That is a pharmacist's daily work, and it is where most of the money hides.

Pharmacist-run

We have been on the other end of these plans.

Pharmacists are the ones who tell you what your prescription costs today. We did that for years. Then we got licensed, so the hard conversation could happen in October instead of January.

Doctors by name

We check your providers, not just the network in general.

Not a vague promise that most plans cover most doctors. We look up your specific physicians and specialists in front of you, before any plan gets named.

Local first, not local only

Northern Colorado is home.

Greeley, Fort Collins, Loveland, Windsor and the towns around them are where we live. We also reach Grand Junction, Palisade and Colorado Springs, and we are licensed in 25 states, so a move or a parent out of state is no trouble.

The best introductions

What the pharmacy relationships are actually for.

Not a referral pipeline and not a pharmacy preference. A better introduction. When a pharmacist calls and says your name and how long they have known you, the conversation starts with a person who has a history instead of a lead off a list. That is most of why we built those relationships.

All year, not just October

You will hear from us in February too.

Letters arrive. Drugs move tiers. A prior authorization gets denied. When that happens you call the same person who set your plan up, and we help you read it. That is the part most people never get.

Ask us anything

Questions about this, answered.

Can I have Medicare and Medicaid at the same time?

Yes. It is called dual eligibility and about twelve million people have both. Medicare pays first on Medicare-covered services and Medicaid pays last, filling in behind it up to your state's payment limit. Medicaid also covers categories Medicare does not, most significantly long-term nursing facility care beyond Medicare's 100-day limit.

What is a D-SNP?

A Dual Eligible Special Needs Plan. It is a Medicare Advantage plan that only enrolls people who have both Medicare and Medicaid, and it holds a contract with the state Medicaid agency so the two programs coordinate rather than leaving you to manage the seam between them. Like all Special Needs Plans it has to include prescription drug coverage.

What is a C-SNP and what conditions qualify?

A Chronic Condition Special Needs Plan is built around one or more severe or disabling chronic conditions, with the network, drug list and care coordination tailored to it. Medicare regulation permits plans to be built around a wide range of conditions including diabetes, chronic heart failure, cardiovascular disease, COPD and other chronic lung conditions, chronic kidney disease, cancer, dementia, autoimmune disorders, chronic mental health conditions, neurologic disorders, and HIV or AIDS. Whether a plan actually exists for your condition in your county is a separate question, and we will give you a straight answer on that.

Does my doctor have to confirm my condition for a C-SNP?

Yes. Either the plan contacts your provider to verify the condition before you enroll, or you complete a qualification assessment that your provider confirms before the end of your first month of coverage. If it is not verified, you get disenrolled at the end of the second month, so it is worth handling right away rather than letting it drift.

Can I get an institutional plan if I live at home?

Often yes, and almost nobody knows this. An Institutional Special Needs Plan covers people who are institutional-equivalent, meaning living in the community but requiring an institutional level of care. It takes a state assessment plus an assessment by an impartial party. If you are caring for a parent at home and the care needs are increasing, this is worth asking about by name.

Does Medicaid pay my Medicare Part B premium?

It can, through a Medicare Savings Program. QMB, SLMB and QI all pay the Part B premium, and QMB goes further by also covering Part A premiums if you owe them, plus deductibles, coinsurance and copayments. These are run by the state and are badly underclaimed. Enrolling in one also eliminates a Part B late enrollment penalty if you have one.

I have QMB but a doctor sent me a bill. Is that allowed?

Generally no. Medicare providers are not allowed to bill someone with QMB for services and items Medicare covers, including deductibles, coinsurance and copayments. If you are getting billed anyway, do not just pay it. Bring us the bill and we will help you sort out where it went wrong.

How often can dual eligibles change plans?

Under current rules, if you have Medicaid or Extra Help you get a once-per-month opportunity to move into a standalone prescription drug plan. Full-benefit dual eligibles also get a monthly opportunity to move into an integrated D-SNP that aligns with their Medicaid plan. These replaced the older quarterly windows. The distinction between the two matters a lot in practice, so it is worth a phone call rather than a guess.

What happens to my plan if I lose Medicaid?

You do not lose the plan that day. If you could reasonably be expected to qualify again within six months, your plan keeps you eligible for a grace period of at least 30 days and up to 6 months, and the plan decides the length. Many websites state a flat six months, which is not the rule. Losing Medicaid also opens a 3-month Special Enrollment Period, so bring us the letter as soon as it arrives.

What are the Extra Help limits for 2026?

Income up to $23,940 for an individual and $32,460 for a married couple, with resources up to $18,090 and $36,100. If you qualify, your drug plan premium and deductible are zero, generics run up to $5.10 and brand names up to $12.65, and after $2,100 in total drug costs you pay nothing for covered drugs. And do not rule yourself out on the numbers, because states do not all count income and resources the same way.

Northern Colorado Medicare help

Bring your medication list. We will read it like pharmacists.

One appointment. Every medication priced tier by tier for the full year, your doctors looked up by name, and no pitch waiting at the end of it.

Book a Medicare Review Call or Text 970.505.9652

Ask us what a plan pays us and we will tell you the number. Haven is paid by the insurer if you enroll, and your premium is the same whether you use a broker or enroll directly.