Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs)
Medicare Advantage, also known as Medicare Part C, is an alternative way to receive Original Medicare (Part A and Part B) benefits. It can be a cost-effective and potential saving option because it has out-of-pocket limits on costs associated with your covered services. Once you reach the limit, you pay nothing for the rest of the year.
Unlike Original Medicare, Medicare Part C is offered by private insurance companies. Federal government rules and regulations, however, regulate these private companies.
Medicare Advantage offers five types of plans. These include:
● Health Maintenance Organization (HMO) plans
● Preferred Provider Organization (PPO) plans
● Private Fee-for-Service (PFFS) plans
● Special Needs Plans (SNPs)
● Medicare savings account (MSA) plans
In this article, we will be discussing Dual Eligible Special Needs Plans (D-SNPs), a sub-type of Special Needs Plans (SNPs). We will also cover who its beneficiaries are, how to be eligible, what it covers, and more.
Special Needs Plans (SNP) Plans
Special Needs Plans are a type of Medicare Advantage Plan. They are network based and will usually be either an HMO SNP or a PPO SNP. The HMO plans will usually be more rich in Extra Benefits than the PPO options but that does come at a cost. HMO’s will require you to get ALL of your healthcare services inside of the plans network. PPO’s will give you freedom to see out-of-network providers but will usually have less benefits as a trade off.
Special Needs Plans are made available to individuals who meet the plan sponsors eligibility requirements. The people usually meet specific health criteria, such as having certain chronic and disabling health conditions or qualifying for both Medicare and Medicaid. These criteria form the two most common types of SNPs. They are Chronic, and Dual Eligible Special Needs Plans (D-SNPs).
Dual Eligible Special Needs Plans (D-SNPs)
People eligible for both Medicare and Medicaid are known as the dual-eligible population. D-SNPs are available to this group of people and are characterized by very low or no costs in terms of premiums, deductibles, copays, and other out-of-pocket expenses.
To qualify for Medicare, you must be 65 years old or older or have a qualifying disability if you are under age 65.
To be eligible for Medicaid, your income and assets must fall below certain limits determined by your state. However, low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) fall under mandatory eligibility groups.
Medicaid Eligibility Categories
Each D-SNP plan will have its own required level of Medicaid to be eligible for the plan. The following is a list of different Medicaid levels someone on Medicare can have:
● Beneficiaries of full Medicaid (only)
● Qualified Medicare beneficiaries without other Medicaid (QMB only)
● Qualified Medicare beneficiaries with Full Medicaid (QMB Plus)
● Specified Low-Income Medicare Beneficiaries without other Medicaid (SLMB Only)
● Specified Low-Income Medicare Beneficiaries with full Medicaid (SLMB Plus)
● Beneficiaries of Qualifying Individual (QI)
● Beneficiaries of Qualifying Disabled and Working Individual (QI)
For a more in depth look at what each of these levels of Medicaid covers and/or does not cover Click Here.
Types Of Dual Eligible Special Needs Plans (D-SNPs)
There are five types of D-SNPs with different degrees of Medicaid coverage. They are:
● All Dual
● Full Benefit
● Medicare Zero Cost Sharing
● Dual Eligible Subset
● Dual Eligible Subset Medicare Zero Cost Sharing
All Dual
Every category of Medicaid eligibility is eligible for All Dual D-SNP. An All Dual D-SNP enrolls beneficiaries who are eligible for Medicare Advantage and those who qualify for Medicaid, whether or not they have full Medicaid benefits.
Full Benefit
A full-benefit D-SNP enrolls beneficiaries who qualify for full Medicaid benefits under any eligibility category or Medical assistance for any month if the individual was eligible for medical assistance in any part of the month.
Medicare Zero Cost Sharing
This type of D-SNP enrolls only Qualified Medicare beneficiaries without other Medicaid (QMB only) and Qualified Medicare beneficiaries with Full Medicaid (QMB Plus). These two categories of the dual-eligible population are not responsible for cost-sharing for Medicare Part A and Medicare Part B.
Dual Eligible Subset
In this type of D-SNP, only members of certain dual-eligible groups determined by a carrier/company’s coordination with a State Medicaid Agency are enrolled.
Dual Eligible Subset Medicare Zero Cost Sharing
In this type of D-SNP, only members of certain dual-eligible groups determined by a carrier/company’s coordination with a State Medicaid Agency are enrolled. However, these beneficiaries are not financially responsible for Medicare cost-sharing.
What Do Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) Cover?
Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) offer the same coverage as Medicare Part A (Inpatient/hospital services) and Part B (outpatient/medical services). They also often provide supplemental coverage meant to help lower income beneficiaries:
● Prescription drug coverage (All D-SNP plans must have prescription drug coverage)
● RoutineVision care, including glasses and contacts
● Routine dental care, including x-rays, exams, and dentures
● Hearing care, including testing and hearing aids
● Wellness programs and gym memberships
● Transportation
● Non-medical services including meal delivery, home air cleaners, and home modifications.
● Some plans may even have monthly allowances for food and/or utility bills
D-SNP plans are not available in all areas. Plan availability varies based on the county that you live in.
When Can I Enroll In A Medicare Advantage Dual Eligible Special Needs Plan (D-SNP)
Even though D-SNPs are Medicare Advantage plans, they have no set enrollment period. Individuals eligible for D-SNP qualify for a Special Enrollment Period (SEP) to join or switch S-DNPs. A Special Enrollment Period (SEP) only comes up when there is a qualifying situation or event for it.
Once eligible for a SEP, enrollment in a D-SNP depends on the month you plan to enroll. In the first nine months (first three quarters) of a calendar year, you may enroll once per quarter using the “Dual Eligible” Special Election Period. Your plan will be effective from the first day of the following month.
However, in the fourth calendar quarter, you can only enroll during the Annual Election Period (AEP), which runs from October 15th through December 7th every year. If you’re already enrolled in Original Medicare or another Medicare Advantage plan, you can change to a Medicare Advantage D-SNP plan during the Medicare Open Enrollment Period if you meet the eligibility requirements of the plan. All changes you make during this period will go into effect on January 1st of the following year.
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