Dual Eligible Special Needs Plans: Are They Right For You?

As of 2020, approximately 12.5 million people have both Medicare and Medicaid coverage. Medicare is a federal health insurance program for people over 65 and certain disabled individuals. Medicaid is a joint federal and state program that helps provide medical care for those with limited income and resources. Medicaid recipients include children, pregnant women, and individuals who are blind or have disabilities.

People with both types of coverage are called “dual eligible.” If you’re one of them, you have several options for coordinating your coverage and care. One option is to have Medicare with separate Medicaid coverage. A second option is enrolling in a Dual Eligible Special Needs Plan (D-SNP).

What Is a Dual Eligible Special Needs Plan?

It is helpful to understand what a Medicare Special Needs Plan (SNP) is to understand D-SNPs. An SNP is a type of Medicare Advantage plan that offers wider Medicare coverage for prescriptions, health and wellness, dental, and other services.

A D-SNP is an SNP for individuals who qualify for both Medicare and Medicaid. It combines these benefits into one managed care plan to simplify access to care for covered individuals.

Dual eligible persons often have complex medical situations and need assistance navigating both systems, and D-SNPs can assist with this process. D-SNPs must be approved by individual states to ensure they meet certain criteria before they can be offered to residents. As of 2022, D-SNPs are available in 46 states.

The type of D-SNP a person can enroll in depends on which Medicaid eligibility category they fall into, so it is critical to confirm with your state which plan you qualify for before signing up for one.

How Do I Qualify for a D-SNP?

Assuming your state offers D-SNPs, if you are eligible for both Medicare and Medicaid, you will most likely qualify for a D-SNP. However, you must meet certain baseline rules:

• You must be a U.S. citizen or permanent resident.
• You must qualify for Medicare Part A and Part B.
• You must meet income and asset requirements for your state’s Medicaid program.

How Can a D-SNP Help Me?

A D-SNP is designed with the goal of improving health care quality and efficiency for members on Medicare and Medicaid. It can help dual eligible individuals, especially those with complex medical needs. D-SNP enrollees can:

• Access more comprehensive health benefits including “extra” benefits beyond those offered through Medicare Parts A and B and Medicaid, such as dental, vision, hearing aids, fitness memberships, coverage of special dietary needs, meal delivery and over-the counter-products, assistance with transportation, and personal care benefits.
• More easily navigate benefits due to working with a health plan that understands the unique needs of dual eligible individuals and how Medicaid and Medicare health benefits intersect.
• Work with a care coordinator that can provide individualized guidance and service to members.

Costs of a D-SNP

Depending on the D-SNP and your particular situation, there may be minimal out-of-pocket costs (“cost-sharing”). How much you pay for cost sharing usually depends on your Medicaid eligibility category.

Generally, Medicare pays its portion of medical, dental, or other expenses covered by D-SNPs first, followed by Medicaid. You would then owe any remaining balance determined in accordance with your cost-sharing responsibility.

Enrolling in a D-SNP

To enroll in a D-SNP, you must be enrolled in Medicare. If you meet other D-SNP requirements, you have the following opportunities to enroll:

• During your initial enrollment period – Once you enroll in Medicare, you will be able to apply for a D-SNP. The initial enrollment period refers to the seven-month period starting three months before your 65th birthday. In addition, special rules that may allow access to a D-SNP sooner may apply to you if you are receiving Social Security or Railroad Retirement Board disability benefits.
• During the general enrollment period, which is January 1 to March 31 each year – In this time period, you can sign up for Medicare Parts A and B if you did not sign up when you were first eligible. You can then sign up for a D-SNP in April through June of that same year.
• During a special enrollment period if a qualifying event occurs – Qualifying events may include such scenarios as:
  • You are in a nursing home, moving into one, or leaving a nursing home. You can enroll in a D-SNP for the first time, switch plans, or leave a plan.
  • You become eligible for Medicaid – you can then enroll in a D-SNP.
  • You move outside the service area covered by your current SNP and want to switch to another plan.
  • Your D-SNP leaves Medicare – you can sign up for a different D-SNP.

D-SNPs are unique plans that can benefit members in many ways, expand their access to medical care, and often accomplish all of this at an affordable rate. If you have questions about whether a D-SNP is right for you, speak with an elder law attorney in your area.

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