What are Dual Eligible Special Needs Plans?
Dual Eligible Special Needs Plans (D-SNPs), a type of Medicare Advantage Plan (Medicare Part C), are for seniors and persons with disabilities who are “dually eligible” (qualify for both Medicaid and Medicare). Administered by private insurance companies, these Medicare managed care plans utilize a specific network of physicians, specialists, and hospitals to combine and coordinate Medicaid and Medicare (Part A, B and D) benefits into a single program. This can include medical and behavioral health benefits, as well as long-term care. While this makes navigating one’s coverage much easier, the level of integration between the two programs varies based on the type of D-SNP.
While nearly all states offer at least one type of D-SNP, enrollment is never mandatory. While a state may opt for automatic enrollment or “default enrollment”, one can opt out or disenroll. Persons can instead receive their Medicare benefits from Original Medicare or a Medicare Advantage plan and their Medicaid benefits from Medicaid. Dually eligible persons can also enroll in the Program of All-Inclusive Care for the Elderly (PACE), which is available in 33 states and the District of Columbia.
For those who choose to enroll in a D-SNP, these plans are heavily monitored. D-SNPs are regulated by the Center for Medicare and Medicaid Services (CMS), which sets minimum requirements for all D-SNPs. State Medicaid agencies also have oversight via a State Medicaid Agency Contract, SMAC, through which additional criteria can be added. A SMAC is required between the D-SNP and the state Medicaid agency in order to operate.
Types of D-SNPs
There are three types of D-SNPs, which offer differing levels of coordination and integration between Medicaid and Medicare benefits.
1) Coordination Only D-SNP (CO D-SNP) – provides all Medicare benefits, but only coordinates Medicaid benefits. Medicaid benefits may be provided through a state’s Medicaid plan or via a Medicaid managed care plan.
2) Highly Integrated D-SNP (HIDE SNP) – provides and coordinates all Medicare benefits and some to most Medicaid benefits.
3) Fully Integrated D-SNP (FIDE SNP) – provides and coordinates all Medicare and Medicaid benefits / services, including Medicaid long-term care, like nursing home care and Home and Community Based Services (HCBS).
Benefits of D-SNPs
All D-SNPs provide coordinated care for persons dually eligible for Medicaid and Medicare. While the exact benefits provided vary by state and specific plan, potential benefits include:
– 24/7 Nursing Line
– Behavioral Health
– Care Coordination
– Dental Services
– Fitness Programs / Gym Memberships
– Hearing – i.e., exams and hearing aids
– Home Health
– Hospital Services (inpatient & outpatient)
– Laboratory Services
– Medical Equipment / Supplies
– Nursing Facility Services
– Over-the Counter Medications / Supplies
– Physical Therapy
– Physician Services
– Prescription Drugs (Medicare Part D)
– Prosthetic Devices
– Telehealth
– Transportation Assistance – i.e., to medical appointments
– Vision Services
– X-rays
D-SNP program beneficiaries generally do not pay out-of-pocket costs, or if they do, they pay very little.
Eligibility Requirements of D-SNPs
To be eligible for a D-SNP, one must be enrolled in Medicaid, have Medicare Parts A (Hospitalization) and Parts B (Medical), and live in an area in which the plan is offered. While some states require persons to have full Medicaid benefits (be fully dual), other states extend eligibility to those who are partially dual. This means that rather than receive full Medicaid benefits, they are enrolled in only a Medicare Savings Program (MSP), like Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB), or Qualifying Individual (QI). MSPs only provide financial assistance with Medicare costs, such as premiums, deductibles, and co-payments.
See state-specific Medicaid eligibility criteria.
See eligibility criteria for MSPs.
See Medicare eligibility criteria.
State-Specific Differences
D-SNP plans are available in the District of Columbia, as well as every state except for Alaska, New Hampshire, and Vermont. However, even in the states where they are available, there may not be a D-SNP plan in every county and / or zip code within a state. States may also offer more than one type of D-SNP.
Since CMS establishes base rules for D-SNPs, while states establish additional requirements through State Medicaid Agency Contracts, D-SNP rules can vary significantly based on the state and specific D-SNP. As mentioned previously, some states and programs require D-SNP participants to be full Medicaid beneficiaries, while others allow partial dual eligibles to enroll. Furthermore, some states may limit enrollment to persons who receive Home and Community Based Services. For instance, Tennessee Medicaid (TennCare) limits enrollments to individuals enrolled in QMB Only (a Medicare Savings Plan), as well as those who receive assistance via a 1915(c) HCBS Medicaid Waiver. Another state-specific difference is that in some states, such as California and Illinois, individuals with a spend down cannot enroll in a D-SNP. In other words, they cannot qualify for a D-SNP if they qualify for Medicaid via the medically needy pathway.
Enrolling in a D-SNP
Individuals not enrolled in Medicare and Medicaid must first apply for these programs. Learn about enrolling in Medicare. To apply for Medicaid, persons should contact their state Medicaid agency.
To find a D-SNP in one’s area, one can call 1-800-MEDICARE or go to Medicare.gov, enter their zip code and mark that they are looking for a Medicare Advantage Plan. When asked if help is received for their Medicare health or drug costs, one must mark “Medicaid”. Persons can also contact SHIP (State Health Insurance Assistance Program) for assistance in finding and comparing D-SNP plans in their area.