Medicare was set up by the federal government with the goal of helping older Americans and those with certain disabilities and conditions get coverage for most of their medical expenses. Today, the program benefits over 63 million people in our country by providing them with access to the care they need.
The Medicare program is divided into four parts, with Part A (hospital insurance) and Part B (medical insurance) -- also known as Original Medicare -- being the two most basic and important components. These two parts must be included in the coverage of every eligible Medicare beneficiary. Part C, known as Medicare Advantage plans, refers to medical coverage offered by private insurance companies that can be used as alternatives to Original Medicare. If you are to enroll in a Medicare Advantage plan, it would replace your original Medicare coverage. At the same time, these plans may include additional benefits outside of what Part A and Part B cover.
But even if you are eligible for Medicare, you may also be entitled to another type of Medicare Advantage plans called the Dual Eligible Special Needs Plans (D-SNPs), with the condition that you fulfil certain state-specific criteria under Medicaid. Put it another way, D-SNPs are for individuals who qualify for both Medicare and Medicaid.
In this blog post, we will cover what a D-SNP is, how you may qualify, and all the information you'll need to make an informed decision on whether it's right for you.
What Does It Mean To be Dual Eligible?
While Medicare have over the years provided healthcare assistance to many eligible Americans, the program is available only to individuals over the age of 65, or those with certain disabilities. This means there is still a huge healthcare coverage gap in our society - in 2022, it was estimated that 44% of working-aged adults struggle to pay for health insurance as well as other out-of-pocket healthcare expenses.
To those who don't meet the conditions to qualify for Medicare, they may still be eligible for Medicaid. This program was designed to help people over the country whose income are below certain threshold with their Medical bills. While the criteria may vary between states, it is generally available to those whose annual income is below the federal poverty level (FPL), which is $14,580 for single adults without children and $24,860 for a three person household.
To be considered dual eligible, you would need to be eligible for both Medicare and Medicaid.
What is the Benefit of Dual Special Needs Plans?
Dual Eligible Special Needs plans (D-SNPs) is a special type of Medicare Advantage plan that packages your Medicare/Medicaid benefits and prescription drug coverage together to offer you a complete and easy healthcare experience. Because D-SNPs include all the benefits of both Medicare and Medicaid programs, you're typically getting the most out of your plan if you qualify for one.
Compared to Original Medicare, these plans usually offer more benefits since they are offered by private insurance companies. But it's important to note that all D-SNPs are jointly funded by the federal government and your state government. This means that your state may have some control over the type, amount, and duration of your benefits, provided they meet certain guidelines.
A typical D-SNP may include benefits such as personalized care coordination, chronic condition management, home health services, over-the-counter benefits, telehealth services, inpatient procedures, outpatient procedures, mental health services, preventative services, medical equipment, dental, vision, hearing, transportation, caregiver support, etc. But as we mentioned, every D-SNP is different, so it's important to check the benefits of the individual plan you're interested in before making a decision.
Who Qualifies for Dual Special Needs Plans?
D-SNPs are available to dual-eligible beneficiaries, meaning you first must qualify for both Medicare and Medicaid. Eligibility is mainly determined by a number of factors such as household income, marital status, etc.
To qualify for a D-SNP you must be a US citizen or permanent legal resident and a resident of the state in which you are receiving benefits. Depending on your state, there may be other criteria you must meet. For more details on eligibility, you can refer to the Centers for Medicare & Medicaid Services website.
What Is Partial Dual Eligible?
A person who is partially dual-eligible is someone who qualifies for the Medicare Savings Program (MSP), which was designed to help low-income individuals with their Medicare costs. There are four types of Medicare savings programs.
Qualified Medicare Beneficiary (QMB): The QMB program covers Part A and B premiums, deductibles, coinsurance, and copayments.
Specified Low-Income Medicare Beneficiary (SLMB): The SLMB program simply pays for Part B Premiums.
Qualifying Individual (QI): The QI program covers Part B Premiums for Medicaid Beneficiaries.
Qualified Disabled and Working Individual (QDWI). The QDWI program helps pay Part A premiums for working individuals under the age of 65, those who lost Part A premium coverage after returning to work, those who do not receive state medical assistance, and those who do not meet the income and resource limit based on their state.
To enroll in a Medicare savings program, you must meet the eligibility requirements based on income and resource level. If you meet certain conditions, you may also be automatically qualified for the Extra Help program, which is a federal program that covers Medicare beneficiaries for prescription drugs (Part D).
What Is a Medically Needy Program?
Many states also offer what is called a Medically Needy Program, or spenddown program. It is made for those who would not typically qualify for dual-eligibility because of their income, but have large healthcare bills due to extensive medical needs.
With this program, individuals may deduct medical expense from their income so that they qualify for Medicaid spend down for aged, blind, and disable (ABD). This is usually for people whose medical expense take up a significant portion of their income. The coverage provided under a Medically Needy program is similar to that of Medicaid, and it typically includes Medicaid services such as doctor visits, hospital stays, prescription drugs, and other medically necessary services.
Is a D-SNP Right for me?
While Medicare Advantage plans typically come with more benefits than original Medicare, there is also downside to them. Since Original Medicare is designed to give you freedom over your healthcare, with this program, you can visit any doctor or hospital in the country..
On the other hand, Medicare Advantage plans may restrict you to doctors, hospitals, or facilities within their network. You may also be required to obtain pre-approval on procedures, prescriptions, or treatments a doctor recommends, before you are allowed to move forward with certain treatment. This can sometimes lead to delays in your care and even allows your insurance company to refuse the treatment you need.
How Much Does a D-SNP Cost?
The cost of a D-SNP also varies depending on a few factors, such as the state you live in, the insurance company offering the plan, and the specific benefits and coverage options included.
In general, if you are eligible for both Medicare and Medicaid, you may be able to enroll in a D-SNP at no additional cost beyond what you already pay for your Medicare and Medicaid premiums. However, some D-SNPs may have additional costs such as copays, deductibles, or coinsurance for certain services or medications.
How Do I Enroll In a D-SNP?
Because dual eligible special needs plans are offered by private insurance companies, you may not have covered access to doctors outside the company's network. If you have a preferred doctor or hospital, you will first want to make sure they are covered by the insurance plan you are interested in.
To enroll in a D-SNP, you will first want choose a plan that is right for you. It's difficult and time-consuming to consider all of your needs and options on your own, and this is an important decision that could lead to you getting stuck in a plan that isn't a fit. As such, it is important that you engage with a professional that will connect you to the best plan available.
If you are looking for an experienced Medicare agent who has your best interest in mind, EASY Insurance Plans will be happy to take the time and discuss your Medicare options.