For the roughly 12 million Americans who are enrolled in both Medicare and Medicaid — a group known as dual eligibles — the sweeping changes now reshaping Medicaid are not an abstract policy debate. They are a direct threat to the financial lifeline that makes healthcare affordable. Understanding what has happened to Medicaid enrollment over the past several years, and what the 2025 reconciliation law means going forward, is essential for any Medicare beneficiary who depends on Medicaid to help cover premiums, deductibles, or long-term care costs.
Medicaid enrollment in the United States has gone through three distinct phases in the past decade. Following the Affordable Care Act's Medicaid expansion in January 2014, states that chose to expand coverage opened their programs to adults earning up to 138% of the federal poverty level — roughly $20,120 for a single person in 2024. Enrollment climbed steadily as more states adopted the expansion, reaching a pre-pandemic peak of approximately 75 million enrollees in March 2017. After that, enrollment declined gradually as the economy improved and some states tightened eligibility verification, falling to about 71 million by February 2020.
Then the COVID-19 pandemic changed everything. Congress passed legislation that required Medicaid programs to keep people continuously enrolled — meaning states could not disenroll anyone for the duration of the public health emergency — in exchange for receiving enhanced federal matching funds. The result was a dramatic surge in enrollment. By March 2023, when the continuous enrollment provision officially ended, national Medicaid and CHIP enrollment had climbed to a record high of 94 million enrollees, according to CMS.gov data tracked through the Performance Indicator Project. That figure represented roughly 28% of the entire U.S. population covered under a single public insurance program.
The unwinding of that continuous enrollment protection began on April 1, 2023, and what followed was one of the largest mass disenrollment events in the program's history. Over the next 16 months, millions of people were removed from Medicaid rolls — some because they genuinely no longer qualified, but many others due to administrative failures: outdated addresses, paperwork backlogs, and state agencies overwhelmed by the volume of redeterminations they had to process simultaneously. According to CMS.gov data compiled through the KFF Medicaid/CHIP Monthly Enrollment Tracker, national enrollment had dropped to approximately 80 million by September 2024. That is a loss of 14 million enrollees in just over a year.
For Medicare beneficiaries, the most important segment of that 80 million figure is the dual-eligible population. Dual eligibles are individuals who qualify for both Medicare and Medicaid simultaneously — typically because they are 65 or older (or disabled) and have very low income and limited assets. Medicaid serves as a critical wraparound for these individuals, paying for costs that Medicare does not cover. Depending on the level of Medicaid coverage a person qualifies for, Medicaid may pay their Medicare Part B premium (which is $185.00 per month in 2025), their Part A and Part B deductibles, their copayments and coinsurance, and in many cases, long-term care services in nursing facilities or home-based settings. Without Medicaid, many of these costs would be completely unaffordable on a fixed Social Security income.
Data Snapshot: According to CMS.gov data from the Medicare-Medicaid Coordination Office, approximately 12.2 million Medicare beneficiaries were dually enrolled in Medicaid as of 2023, representing about 18% of all Medicare enrollees. Among full-benefit dual eligibles — those who receive the most comprehensive Medicaid coverage — the average annual Medicaid expenditure per person exceeds $20,000, reflecting the high cost of long-term services and supports that this population disproportionately uses. These figures underscore why any reduction in Medicaid eligibility is not a minor inconvenience for this group — it is a potential financial catastrophe.
Enrollment stabilized briefly at the end of 2024, but according to the KFF tracker, declines resumed in March 2025. And now, a new and more structural threat has emerged. The 2025 reconciliation bill, passed by Congress and signed into law in July 2025, introduces the most significant changes to Medicaid eligibility rules in the program's history. For the first time ever, the law conditions Medicaid eligibility for expansion enrollees on meeting work and reporting requirements. This means that adults in the Medicaid expansion group — those who gained coverage under the ACA because their income fell between 100% and 138% of the federal poverty level — will be required to demonstrate that they are working, in job training, attending school, or performing community service for a minimum number of hours per month in order to maintain their coverage.
The practical implications of these work requirements are significant and, for many beneficiaries, deeply concerning. Older adults who are in the Medicaid expansion group but not yet 65 — say, a 62-year-old who retired early due to a health condition — may find themselves subject to these requirements even if they are functionally unable to work. The law does include exemptions for certain groups, including those who are medically frail or have a disability, but the burden of proving exemption status typically falls on the enrollee, and the documentation and reporting requirements can be difficult to navigate, particularly for individuals with limited digital access or health literacy challenges.
For Medicare beneficiaries specifically, the most direct concern involves the Medicaid Savings Programs (MSPs), which are the four categories of limited Medicaid benefits designed specifically to help Medicare enrollees with their out-of-pocket costs. These programs — the Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualifying Individual (QI) program, and the Qualified Disabled and Working Individuals (QDWI) program — are not part of the Medicaid expansion and are therefore not directly subject to the new work requirements. However, if a beneficiary was receiving full Medicaid benefits through the expansion and is disenrolled due to work requirement failures, they may lose their full dual-eligible status and need to reapply for a more limited MSP benefit instead — a process that requires its own application and income verification.
The income thresholds for the MSPs in 2025 are as follows: QMB covers individuals with income up to 100% of the federal poverty level (approximately $15,060 for a single person); SLMB covers those between 100% and 120% FPL; and QI covers those between 120% and 135% FPL. These programs do not have asset tests in most states, which makes them accessible to people who have modest savings but limited monthly income. If you are a Medicare beneficiary and your income falls within these ranges, you may qualify for an MSP even if you do not qualify for full Medicaid — and applying is free through your state Medicaid agency.
State variation matters enormously in this landscape. Not all states adopted the ACA Medicaid expansion, and the new work requirements apply only to expansion enrollees. As of mid-2025, ten states had not expanded Medicaid, meaning their low-income residents had no pathway to expansion coverage in the first place. In expansion states, the timeline for implementing work requirements varies, and some states may face legal challenges that delay or modify implementation. Your state Medicaid agency's website is the most reliable source for understanding exactly when and how these rules will take effect where you live. You can find your state agency's contact information at Medicaid.gov.
If you are currently enrolled in a Medicare Advantage plan and also receive Medicaid, you may be enrolled in what is called a Dual Eligible Special Needs Plan, or D-SNP. These are Medicare Advantage plans specifically designed for dual eligibles, and they coordinate benefits between Medicare and Medicaid to reduce administrative complexity. In 2025, there are hundreds of D-SNP options available across the country, and they often include extra benefits such as dental, vision, hearing, and transportation that standard Medicare Advantage plans may not offer. If your Medicaid status changes due to the new work requirements or any other reason, your eligibility for a D-SNP may also change — which is why monitoring your Medicaid enrollment status is not just a Medicaid issue, it is a Medicare Advantage issue as well.
The Annual Enrollment Period for Medicare Advantage runs from October 15 through December 7 each year, and the Open Enrollment Period runs from January 1 through March 31. However, dual eligibles have a special enrollment period that allows them to switch Medicare Advantage plans once per quarter during the first three quarters of the year — a flexibility that standard Medicare beneficiaries do not have. If your Medicaid status changes and you need to find a new plan, this quarterly SEP may be available to you. Contact 1-800-MEDICARE or your local SHIP office to confirm your eligibility for a special enrollment period before making any plan changes.
The broader trajectory of Medicaid enrollment — from 71 million before the pandemic, to 94 million at the peak, back down to 80 million and still falling — reflects how sensitive this program is to policy decisions made in Washington and in state capitals. For Medicare beneficiaries who depend on Medicaid as a financial backstop, the message is clear: do not assume your coverage is secure. Verify your enrollment status with your state Medicaid agency, understand which benefits you receive through Medicaid versus Medicare, and reach out to a free SHIP counselor in your state if you are unsure how the 2025 changes affect you. SHIP counselors are available in every state and can provide one-on-one guidance at no cost. Find your local SHIP at shiphelp.org.