Issues You Might Face With D-SNPs

Takeaways

• Dual Eligible Special Needs Plans (D-SNPs) can simplify Medicare and Medicaid coverage, but they don’t always coordinate benefits the same way.
• Common challenges include prior authorization denials, narrow networks, billing confusion, and fragmented communication.
• You can often fix issues by documenting calls, asking for a care manager, and appealing quickly when care is denied.

Millions of Americans qualify for both Medicare and Medicaid. For these “dual eligibles,” managing two separate health care programs can be confusing.

A Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage plan designed for people who have both Medicare and Medicaid. D-SNPs were created to help make coverage easier by bringing Medicare and Medicaid benefits together under one managed care plan.

But while these plans hold real promise, enrollees often face significant challenges. Here are the most common problems – and practical steps to address them.

Not All D-SNPs Coordinate Benefits the Same Way

Some D-SNPs do a better job than others at coordinating Medicare and Medicaid.

Some plans share information but still leave you dealing with Medicare and Medicaid separately at times. More integrated D-SNPs may offer simpler communication, stronger care coordination, and a smoother experience when problems involve both programs.

Before you enroll (or if you’re already enrolled), ask the plan:

• “Do I have one phone number for Medicare and Medicaid questions?”
• “Will I have a care manager?”
• “If something is denied, do I appeal in one place or two?”

Prior Authorization Denials

Many Medicare Advantage plans, including D-SNPs, require prior authorization for certain services, equipment, or medications. That means the plan reviews the request before you receive the service. Sometimes the plan says no, even when your clinician believes the care is necessary; you have the right to appeal such denials.

What you can do:

• Request the denial in writing.
• Ask your plan about the appeals process, as well as what information is missing (if they say it’s a documentation issue).
• Act quickly; deadlines for appeals are strict.

Narrow Provider Networks and Billing Confusion

D-SNPs may have limited provider networks. Even when a provider is “in network” for the Medicare side, billing can get messy if the office is unsure how your Medicaid coverage fits in.

What you can do:

• Before an appointment, confirm with both the provider and your plan that the provider accepts your specific D-SNP and your Medicaid coverage.
• If you have complex medical needs or see multiple specialists, request a care manager. Care managers can help you navigate common coordination challenges, complete appeals, and gather supporting documents.
• If your plan can’t meet your needs with in-network providers, ask your plan what options exist for getting an out-of-network exception or help finding a specialist.

Confusing or Fragmented Communications

Some enrollees receive multiple handbooks, letters, and customer service numbers, leaving them uncertain about which benefits come from Medicare and which come from Medicaid.

What you can do:

• Ask your plan for a single point of contact: “Who should I call for Medicare and Medicaid questions?”
• Keep a simple call log. On each letter (or in a notebook), write the date you called, the phone number you used, whom you spoke with, and what they told you.
• When you reach someone, start with a clarifying question: “Is this covered under my Medicare benefits, my Medicaid benefits, or both?”
• If your plan offers care manager services, use them.

Unexpected or Unwanted Enrollment

Some people are automatically enrolled in a D-SNP (for example, when coverage changes or when plans and states align benefits). If you didn’t actively choose the plan, you may worry about whether you can keep seeing the same doctors.

What you can do:

• Open plan notices right away and watch for effective dates.
• If the plan isn’t a good fit, ask about your options to switch plans (you can opt out before enrollment becomes effective).
• Contact your local State Health Insurance Assistance Program (SHIP) for free, unbiased help from a counselor who can explain your options.

Where to Get Help

• For free, one-on-one Medicare counseling, find your local SHIP at shiphelp.org.
• Extensive plain-language resources on D-SNPs and dual eligibility rights information (including these D-SNP FAQs) are available through the nonprofit Justice in Aging.
• Visit Medicare.gov for information on Special Needs Plans.

D-SNPs can be a valuable option for people navigating both Medicare and Medicaid. Know your rights and get the support you need.