About 12 million people in the U.S. qualify for both Medicare and Medicaid, which means they are dual eligible. Dual Eligible Special Needs Plans (D-SNP) are an important type of financial tool for many people. However, you need to understand what they are and how they work to ensure you take full advantage of them.
What Are Dual Special Needs Plans?
Medicare is a federal government benefits program that may pay for the health care costs of those who are over the age of 65 or qualify for a Medicare-approved disability. Medicaid is a bit different. It is a state focused program that provides medical healthcare coverage to people who meet the state’s requirements. It is not based on age but rather on income and medical conditions. Some people may qualify for both, making them dual eligible. Dual Special Needs Plans could help you to maximize the coverage you have.
These plans are a type of Medicare Special Needs Plan (SNP). SNPs are a Medicare Advantage plan, which is also sometimes referred to as Medicare Part C. Let’s break down this rather complicated process.
What Is a Medicare Advantage Plan?
As noted, SNPs are a type of Medicare Advantage Plan. This type of plan replaced Original Medicare (which is also referred to as Part A and Part B). Instead, you purchase a Medicare Advantage plan that helps to provide all of your coverage, including Part A (hospital coverage), Part B (medical care), and in some cases, prescription drug coverage as well. Medicare Advantage plans are a very common choice because you can add features to them that fit your needs, like dental, vision, and hearing insurance. They also offer access to things like medical appointments, transportation and fitness programs.
Medicare Advantage Plans are provided by third-party organizations. There are many of them. Each is a bit different in what it covers and what it does not. This gives you the ability to find what works for your needs.
What Is a Medicare Special Needs Plan?
A Medicare SNP is a type of managed care plan. It helps to provide coverage for a limited population or a special group of people. Most of the time, an SNP is designed to meet the specific needs of those who are members of it. In most cases, SNPs are tailored to people who have a specific medical condition or may be low income. Some are designed for those who have unique healthcare requirements.
What Types of SNPs Are There?
There are several types of SNPs, each one with a specific area of focus in what they offer coverage for. Here is a look at several of them.
What Is a Chronic Condition SNP?
Also known as a C-SNP, this type of plan is designed to meet the needs of people who have a disabling chronic condition. Generally, this is a severe condition that is not likely to improve over the long term. It could include conditions like dementia, chronic heart failure, End-Stage Renal Disease, and HIV/AIDs. If you meet the medical requirements and diagnosis of these conditions, you may qualify for this C-SNP.
What Is an Institutional SNP?
Another type of SNP is called an institutional SNP or I-SNP. This type of program is designed for people who need to live within a specific type of community. Most of the time, this applies to those who need to be in a nursing home due to health conditions and the need for ongoing support. It does not apply to people in assisted living communities. It may apply, in some situations, to those who need ongoing, significant nursing care in their home.
What Is a Dual Eligible Special Needs Plan?
A D-SNP is a type of SNP. It is a type of managed care plan that is designed specifically to meet the needs of people who qualify for their state’s Medicaid assistance program and Medicare. As a managed care plan, it works to combine the coverages that you qualify for and allows you to make it easy to get the coverage you have.
There are differences in D-SNPs from one state to the next – and it is important for you to learn what applies specifically in your state. Your state also determines the following:
- Who is eligible for the plan
- The access to Medicaid benefits
- And the amount of assistance provided to cover premiums as well as the amount of cost sharing
How Do D-SNPs Differ from Medicare Advantage Plans?
A D-SNP is a type of Medicare Advantage plan, but it is unique in the way it functions and in the services it provides. First, there is eligibility. Not everyone who purchases and is eligible for a Medicare Advantage Plan is qualified for Medicaid. Medicaid is typically income-based, and not everyone will meet those state-set requirements.
D-SNPs are for those that do have eligibility for both Medicare and Medicaid. If you qualify for both of these services, then it may be beneficial to you to consider a D-SNP instead of other types of Medicare Advantage plans. There are a few other notable differences to consider in these plans, too.
A significant difference you will find in D-SNPs is the access to a dual-plan care coordinator. These are people that are there to support you. They work for the insurance provider. Their goal is to help you to make the most of your plan and help you to overcome some of the challenges of getting the medical care you need. The care coordinators will help you find the specialists you need and the doctors necessary to manage your care.
What makes these professionals helpful is that they can help you navigate both plans at one time – that means helping you to find the specialists you need that accept both Medicaid and Medicare, which can be challenging. This way, you are using more of your coverage and have lower out of pocket costs.
Additional Benefits of D-SNP
A number of other D-SNP benefits exist that make these plans an attractive option for many people. First, know that all Advantage Plans must provide some coverage – Part A and Part B. Advantage plans often include other benefits like coverage for prescription drugs and vision coverage, and dental coverage.
However, D-SNPs also go further and provide some added benefits. Though these plans differ from one to the next, they may offer some nice health benefits that not all Advantage Plans cover. This could include coverage for:
- Acupuncture visits
- Podiatry services
- Monthly healthy food allowances
- Personal emergency response systems
- Personal home care support like meal prep help and house cleaning
- Over the counter health products like toothpaste and vitamins
Another key reason why you may wish to choose this type of coverage over others is simple, it tends to cost less. All of these benefits are a nice feature, and having access to support in navigating available healthcare providers is also a nice benefit.
Most of the time, the cost of joining a Medicare D-SNP is covered if you have Medicare and Medicaid eligibility.
Do You Qualify for a D-SNP?
How do you know if you qualify for this plan? Generally, you’ll need to:
- Be a U.S. citizen or otherwise lawfully present in the U.S. as a permanent resident
- Qualify for Original Medicare (Part A and B), which is generally for those over the age of 65 or those with qualified disabilities
- Meet the state requirements for Medicaid, which is usually based on income and asset ownership
- Live within the region where the D-SNPs are available and provide coverage
You may be required to meet other requirements based on the state’s requirements as well as the plan you select. You will want to choose a plan that fits your specific needs.
Why Should You Consider a D-SNP?
It is not uncommon for those who have a significant medical need to be frustrated with the coverage they get from Medicare. It can still be expensive to get the coverage you need. There are some notable reasons why you should consider your D-SNP coverage.
You have a significant need
If you need the requirements for this coverage, then it may be because you are one of the many people that has the greatest need for financial help to cover your needs. You receive more benefits through this type of service. If you need the most comprehensive level of health benefits possible, these are some of the best options in Medicare plans.
You want a hassle-free solution
The additional benefits of these plans are nice, but for many people, just having help navigating the care options you need, including finding a primary care doctor and specialists you need, can help. In many cases, these health plans offer a personal care team that makes it far easier for you to navigate your benefits. The personal care team is designed to help you arrange for the services you need, which helps you make the most out of the additional benefits available to you.
You need more than what Medicare alone offers
As noted, SNP members gain benefits to more benefits than what they can get from just having Medicare plans. You may benefit from these plans if you need or want:
- A gym membership
- Dental coverage
- Eyeglass and contact lenses
- Hearing aids
- Healthy foods access
- Transportation assistance
- Meal delivery service
How Much Does a D-SNP Cost?
The costs that you pay for these Medicare and Medicaid benefits are dependent on many things. First, each provider of Dual Eligible Special needs coverage can set their own costs. This differs based on where you live. You also will need to consider the extra benefits you want and need, as well as the Medicaid eligibility you have, including how much coverage they offer.
Let’s break down the expected costs for D-SNPs:
You are likely to pay your Medicare Part B premium. This premium is dependent on the plan you select. However, costs can range widely based on the plan selected. Expect to pay your Medicare Part B medical premium in all cases.
D SNP plans cost
The D SNP benefits may come with a cost to you. Monthly plan premiums are varied significantly based on your location. However, it may be possible to get dual special plans for as little as $0.
A deductible is another component of some D SNP plans. This is the amount of money you will pay before the health plan kicks in to cover some of the costs. You can choose a policy that offers the deductible that fits your needs.
A copayment or copay is a payment you make when you receive service. This is often paid when you visit with health care providers or when you pick up your prescription drugs. It is typically a set amount of money.
Coinsurance may apply in some situations. This is the percentage of the cost you will pay after your deductible is met.
What Are Medicaid Eligibility Categories?
When comparing D SNPs, you may hear about Medicaid eligibility categories. This is a term that is often related to determining who qualifies for Medicaid. As noted, states cover some of the costs related to Medicaid benefits. That is why Medicaid eligibility can differ from one provider to the next.
Medical eligibility categories are all the categories in which Medicaid may become available. That is, if you may fit into any of these categories:
- Full Medicaid – only
- Qualified Medicare Beneficial (QMB only), meaning you do not have any other Medicaid
- QMB Plus
- Specific Low-Income Medicare Beneficiary (SLMB Only)
- SLMB Plus
- Qualifying Individual (QI)
- Qualified Disabled and Working Individual (QDWI)
When Can I Enroll in a D-SNP?
Now that you are considering the benefits of a D-SNP, you may be unsure how to get one into place. Most of the time, you have to first be enrolled in Original Medicare. That means you have to meet the qualifications for Original Medicare as your first step.
Then, you can start looking at your options in Medicare Advantage D-SNP plans. However, there are only a handful of times when you can actually enroll in D SNPs.
Initial Enrollment Period
Many people will qualify for Dual Eligible Special Needs enrollment during this initial period. This period is 7 months long. It begins 3 months before your 65th birthday, the month of your 65th birthday, and then 3 months after your 65th birthday. You will be alerted to coverage options heading into this period of time by Medicare. You can also compare Dual Speed Needs Plan options at that time.
General Enrollment Period
The general enrollment period runs from January 1 through March 31 each year. During this period, you may be able to sign up for Medicare Part A and Medicare Part B coverage if you did not enroll in the plan when you were first eligible to do so. Once you do that, you then become eligible to sign up for Medicare Advantage Plans, including Needs Plans D SNPs from April through June of that year.
Annual Enrollment Period
Each year, you have the ability to change the health plans you have, which may mean you can compare other healthcare providers to find which one better meets your needs. During the annual enrollment period, you can switch from one plan to the other. This plan runs from October 15 through December 7 each year.
During your annual enrollment period, you are able to sign up for a dual special needs plan or switch to a new plan. You may also use this period to change your Part D coverage. If you have Original Medicare but want to move to an Advantage plan, you can make that switch during this period as well.
Special Enrollment Period
Some people may not be able to wait for one of these periods to qualify for coverage. You may qualify for dual eligible special needs plans during a special enrollment period if you experience a qualifying life event.
There are various life events that may help you qualify for coverage. For example, you may be moving out of the service area your current policy covers, meaning you will likely need a new doctor’s office in a different area. If that new primary care provider is not on the plan you have, you may qualify for a switch.
Also, some people will become eligible for Medicaid due to income loss or other reasons in the middle of the year. If you meet the qualifications for Medicaid services, you may be able to enroll in these plans at that time.
Some people may be in a special needs plan like this, but they lose their eligibility. If that is the case, you have a special enrollment period where you can disenroll. You can then move into an Advantage plan or Original Medicare Parts A and B.
Answering Your Biggest Questions
Many people have questions about these plans, and that makes sense because they can be rather complex. Here are some of the most common questions and answers.
Will the extra benefits provided by these plans cost me more money?
One of the key things to know about these plans is that all these benefits may be provided to you without extra cost. For example, you may be able to get over the counter products sent to your home without any charge to you. It is just part of your policy. To know how much this type of policy will cost you, consider applying for it and comparing several plans. That way, you can see if the extra cost, if there is any, is worth it to you. Not everyone will pay more.
I don’t have a lot of income. Could I qualify?
Medicaid services are often tied to the amount of income a person has as well as the value of their assets. You may qualify for these plans if you do not have income or your income is under the eligibility requirements set by your state. Keep in mind that the value of your assets also matters. The state may force you to liquidate some assets in order to qualify for Medicaid.
How do I enroll in Medicaid?
Medicaid is typically a state-run program. In order to receive Medicaid services, you will need to enroll through your state’s Medicaid offices. You can find out more information about your state’s Medicaid coverage by visiting Medicaid.gov.
Can you have Medicare and Medicaid at the same time?
Yes, as noted, many people will qualify for both Medicare and Medicaid. If you do, you are said to be dual eligible. Most of the time this happens if:
- You are over the age of 65
- Have low income and low assets
- Have a disability and have limited income or assets
How Do I Enroll in a D-SNP?
If you believe you are eligible for this type of coverage, it is a good idea to take a bit of time to compare policies and plans to be sure you get the level and type of coverage best suited for your needs.
We can help you to do this. Turn to our team for help in comparing policies and finding the best plan to meet your individual needs. It’s a good idea to consider a variety of factors in making this decision, including:
- Your medical needs, including any specific chronic condition you have
- Your budget for premiums and other costs
- The type of added benefits that you need and want
- Your need for special services like home delivery or in-home care
- What is available in your service area
Many people benefit from having special needs plans. Yet, remember that not all of these plans are equal in what they offer. That is why you should compare several of your eligible special needs plan options to find one that is going to give you the financial peace of mind and support you need. Reaching out for help is always well worth it.