The Medicare landscape is constantly evolving, and within it, a critical group remains largely overlooked: the Dual Eligibles. This group, comprising around 12 million Americans or 20% of the Medicare demographic, finds itself at the crossroads of Medicare and Medicaid eligibility..png?width=400&height=225&name=Guide%20to%20DSNP%20Video%20Thumbnail(small).png)
Surprisingly, fewer than 30% of Dual Eligibles are taking advantage of Medicare Advantage or Special Needs Plans (D-SNPs). This gap has sparked a significant increase in the availability of Special Needs Plans and brought this demographic to the forefront of Medicare Advantage providers' strategies across the country.
For licensed agents specializing in Medicare offerings, delving into the Dual Eligible/Special Needs Plan arena is a strategic move. The distinct enrollment periods and rules for D-SNPs open the door to continuous sales opportunities, bypassing the constraints of the Annual Enrollment Period (AEP) and the Open Enrollment Period (OEP).
Dual Eligible Special Needs Plans, commonly known as D-SNPs, represent a unique category within Medicare Advantage plans, tailored specifically for individuals who simultaneously qualify for both Medicare and Medicaid.
The availability of D-SNPs, along with the scope of benefits they offer, is determined by state regulations. Typically, these plans might include a variety of benefits without any monthly premiums, such as:
No-cost premiums
Support for coordinating care
Benefits for vision and hearing care
Quarterly allowances for over-the-counter items
Transportation services
Access to telehealth
Gym memberships
Coverage for prescription drugs under Part D
D-SNPs consolidate hospital care (covered under Medicare Part A), medical services (covered under Medicare Part B), and prescription medication (covered under Medicare Part D) into a cohesive plan. These plans often provide additional social services to assist in managing the dual benefits of Medicare and Medicaid for beneficiaries.
It’s important to note the difference between a D-SNP and a Medicare Advantage Medicare-Medicaid Plan (MMP). D-SNPs cater to a broader dual-eligible population, while MMPs are designed exclusively for those fully eligible for both Medicare and Medicaid, subject to more restrictive state-specific criteria. MMPs, introduced in 2014, are available in limited counties nationwide.
D-SNPs are categorized into five distinct types, each offering different levels of Medicaid coverage:
All Dual
Full Benefit
Medicare Zero Cost Sharing
Dual Eligible Subset
Dual Eligible Subset Medicare Zero Cost Sharing
The specifics of these categories will be elaborated on in the following sections.
Eligibility for the Dual Eligible Special Needs Plan (D-SNP) requires simultaneous qualification for both Medicare and Medicaid programs.
To be eligible for Medicare, individuals must either be aged 65 or older, or possess a qualifying disability.
Medicaid eligibility hinges on an individual's financial status, necessitating that both their income and assets do not exceed specific thresholds set by their respective state.
The D-SNP program specifically caters to this intersecting demographic, characterized by the following attributes:
1. Members are simultaneously enrolled in both Medicare and Medicaid, fulfilling the eligibility criteria for each.
2. This group represents a more susceptible segment of Medicare beneficiaries.
3. It encompasses individuals both above and below the age of 65, including those who are eligible due to disability.
4. Their healthcare needs often lead to higher costs.
5. Eligibility for Medicaid typically signifies lower income levels and a self-reported poorer health status in comparison to other Medicare beneficiaries.
Individuals who are dual eligible can be categorized into one of seven distinct Medicaid eligibility brackets. It's important to note that eligibility criteria can differ from state to state, introducing variations in these categories. Broadly, the categories for Medicaid eligibility are as follows:
Qualified Medicare Beneficiary (QMB) Only
QMB Plus
Specified Low-Income Medicare Beneficiary without additional Medicaid (SLMB) Only
Specified Low-Income Medicare Beneficiary with additional Medicaid (SLMB) Plus
Qualifying Individual (QI)
Qualified Disabled and Working Individual (QDWI)
Other Full Benefit Dual Eligible (FBDE)
Below, you'll find a chart detailing which D SNP types individuals might be eligible for, based on their Medicaid category. It's worth mentioning that Special Needs Plans may not be accessible in all areas across the United States. For further information on these or any other plans, we encourage you to reach out to our knowledgeable marketing team.
Individuals eligible for Dual Special Needs Plans (D-SNPs) typically inhabit urban or economically challenged regions. Their reliance on Welfare and Social Security benefits provides a valuable indicator for your outreach efforts.
The timing and location of your search are equally critical. Below are tailored suggestions to guide your initial steps.
In the first half of the month, focus on:
Discount outlets
Dollar shops
Flea markets
Second-hand stores
During the latter half, shift attention to:
Food assistance centers
Community soup kitchens
Local food pantries
Consistently throughout the month, engage at:
Community hubs
Affordable housing complexes
Food pantries again due to their critical role
Religious organizations
Charitable gatherings
Remember, this audience faces multiple hurdles and will require extra effort from you to grasp the full advantages of D-SNPs. Success in this arena belongs to those with a genuine desire to make a difference.
Merely distributing flyers and business cards is not enough to foster meaningful connections. Direct, on-the-ground interaction is essential for effectively communicating with this demographic, who often benefit from additional support and clarity.
Investing time and showing up in their environment can be either challenging or rewarding, influenced largely by your approach and attitude.
If you're open to setting up information booths at local events, or lending a hand at community centers and food banks, then engaging with the D-SNP market could significantly benefit your business.
Dual Eligible beneficiaries can join or switch D SNPs more often than other plans, so a human touch is required.
They will need to know you have their best interest in mind and that you can genuinely help them. At the end of the day it’s not rocket science.
Like any group of customers, the only way to keep them from moving their business elsewhere is by taking good care of them.
D SNPs can be a great way to grow your business all year round. By being a go to resource on special needs plans you will be rewarded by a loyal group of clients.
Note: Ensure you are following all CMS guidelines to stay compliant. The Special Needs Plan FAQ from CMS can also help answer any questions you may have.
*For agent use only. *Not affiliated with the U.S. Government or federal Medicare program.
