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What Is a Medicare Dual-Eligible Special Needs Plan (D-SNP)?

A Dual Eligible Special Needs Plan, or D-SNP, is a type of Medicare plan for individuals who are eligible for both Medicare and their state’s Medicaid program. D-SNPs help coordinate Medicare and Medicaid benefits to help patients manage their costs and get the healthcare services they need. Read on to learn more about special needs plans, how D-SNPs work, why and how to enroll, and how medical redetermination may affect D-SNP enrollment.

What Are Medicare Special Needs Plans?

Medicare SNPs provide healthcare services and benefits to individuals with specific healthcare needs or economic challenges. SNPs are either Health Management Organization (HMO) or Preferred Provider Organization (PPO) plan types, and they cover the same benefits as Medicare Part A and Medicare Part B. Depending on the plan type, they may also include cost-sharing benefits or cover additional services.

There are three types of SNPs: Dual Eligible (D-SNP), Chronic Condition (C-SNP), and Institutional (I-SNP). If you have a chronic condition such as cancer, chronic heart failure, end-stage liver disease, or HIV/AIDS, you may be eligible for a C-SNP. If you live in the community but need the level of care offered by a care facility, an I-SNP may be available.

D-SNPs are designed for individuals enrolled in Medicare Part A and B but are also eligible for state-level Medicaid based on their income. D-SNPs help coordinate Medicare and Medicaid benefits for these individuals.

What Is Medicaid and Medicare?

Medicaid is a joint federal/state program that helps cover the cost of healthcare services for individuals with limited income or resources. While the federal government sets general Medicaid rules that states must follow, states are responsible for managing their own programs. As a result, eligibility requirements and healthcare benefits can vary by state. 

Meanwhile, Medicare is a federal health insurance program available to individuals 65 or older and those younger than 65 if they have specific conditions or disabilities. Medicare is a federally managed program run by the Centers for Medicare and Medicaid Services (CMS). This means that no matter where enrollees live, their Part A and Part B benefits remain the same. 

How Does a D-SNP Work?

A D-SNP works by coordinating Medicare and Medicaid benefits on behalf of plan members. For example, both Medicare and Medicaid provide inpatient hospital services. Depending on the Medicare plan type — HMO, PPO, EPO, or POS — costs for a hospital stay may vary depending on the length of stay and the services provided. Medicaid helps offset these costs for low-income individuals and families. Because each state has its own set of Medicaid criteria, benefits, and services differ depending on where patients live.

D-SNP plans handle the coordination of Medicare and Medicaid. This means that if patients are in the hospital, D-SNPs utilize Medicaid benefits wherever possible to cover the cost of Medicare services. 

This sets D-SNPs apart from both non-SNP Medicare and other SNP plans. In non-SNP Medicare, patients are responsible for the extra cost of services above and beyond their Medicare coverage limits. In C-SNPs, additional benefits are offered to help manage the symptoms of chronic conditions and services needed to address the progression of chronic diseases. In I-SNPs, plans may provide additional coverage for in-home healthcare services. Further, their popularity continues to increase. As of 2023, more than 5 million Americans are enrolled in D-SNP plans. 

Medicaid Eligibility Criteria

Eligibility for Medicaid is determined by a combination of state and federal rules. For example, some states may restrict eligibility by categories such as age or parenting status. Most states require beneficiaries to reside in the state they receive Medicaid. 

The federal government, meanwhile, sets the methodology for income-based eligibility. The current method is based on modified adjusted gross income (MAGI). This metric is used to determine eligibility for CHIP, Medicaid, tax credits, and cost-sharing reductions across the Healthcare Marketplace.

D-SNP Eligibility Criteria

To enroll in a D-SNP, individuals must be U.S. citizens or lawful residents. In addition, they must be eligible for Medicare Parts A and B while also meeting the income requirements for their state’s Medicaid program. The latter requirement includes those who are eligible for:

  • Full Medicaid coverage
  • Qualified Medicare Beneficiary (QMB) or QMB Plus
  • Specified Low-Income Medicare Beneficiary (SLMB) or SLMB Plus
  • Qualifying Individual (QI)
  • Qualified Disabled and Working Individual (QDWI)

Finally, individuals must live within a D-SNP plan’s service area. Different plan providers may offer different coverage areas for Special Needs Plans.

Why Enroll in a D-SNP?

If you are eligible for a D-SNP, there are several reasons to consider enrollment, including:

  • Improved benefit management: Members of D-SNP plans are assigned care coordinators to help manage their benefits across Medicare and Medicaid plans. 
  • Reduced healthcare costs: Under a D-SNP, Medicare pays its portion of healthcare costs first. Any remaining costs are then sent to Medicaid, also known as the second payer. In most cases, the result is little to no out-of-pocket costs for patients. 
  • Access to additional services: D-SNP plans may also offer extra benefits to help keep healthcare costs down. These may include dental and vision coverage, transportation assistance, or a food allowance

How to Enroll in a D-SNP

To enroll in a D-SNP, follow these steps.

  1. Check your eligibility: If you are an American citizen and lawful resident, can enroll in both Medicare and Medicaid, and live in a D-SNP coverage area for your insurance provider, you are likely eligible. 
  2. Contact your healthcare insurance provider: Next, contact your insurance provider. Some providers allow you to make a D-SNP application online, while others may ask you to call them directly. 
  3. Provide required documentation: Be prepared to provide proof of your current income and show that you are currently enrolled in Medicare with your Medicare card or existing insurance documents. 

Medicaid Redetermination May Affect D-SNP Enrollment

Medicaid redetermination is the reevaluation of eligibility for individuals on SNP and other specialized care plans. This redetermination was paused during COVID to help reduce the risk of coverage loss for Americans, but as of April 23, 2023, redetermination — also known as “unwinding” — has restarted. 

As a result, this may be the first time that individuals who received D-SNP coverage during COVID-19 find their coverage reevaluated. If it is determined that you no longer qualify for Medicaid, you may be involuntarily disenrolled. To help mitigate the impact, processes have been put in place that allow insurers to keep patients enrolled if it is reasonable to expect that they will qualify for Medicaid again within the six months following reevaluation. 

Putting It All Together

Dual Eligible Special Needs Plans provide a way for individuals to better coordinate their Medicare and Medicaid coverage. These plans can reduce care complexity and help lower the chance that patients end up paying out of pocket under Medicare for services that could be covered by Medicaid.

To enroll in a D-SNP plan, individuals must be eligible for both Medicare and Medicaid and be able to show that they currently have Part A and Part B coverage. Continued enrollment depends on continued eligibility for both Medicare and Medicaid and is redetermined every year. 

Frequently Asked Questions

All SNPs must provide Medicare drug coverage, also known as Part D. In D-SNPs, this drug coverage is coordinated with Medicaid plans to help reduce patient’s out-of-pocket costs. Drug formularies may differ based on the insurance provider but must include at least two drug types in each of the most commonly prescribed categories. 

If you lose your Medicaid eligibility while enrolled in a D-SNP, you may be involuntarily disenrolled. However, if your insurer determines that you can be “reasonably expected” to meet eligibility criteria again within the next six months, they can choose to extend your eligibility for at least 30 days but no more than six months.

For example, if your income briefly increases, but you can demonstrate to your insurer that this is a result of seasonal work or other income sources that are not reliable, you may be able to keep your D-SNP status. 

No. If you have a chronic illness or a disability that makes living within the community more difficult, you may be better served by an I-SNP or C-SNP plan. It is worth noting, however, that all SNP plans come with a care coordinator who is tasked with helping you make the most of your healthcare benefits. If you are on a D-SNP plan and also have a chronic illness or disability, speak with your care coordinator to see what options are available. 

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