Dual Eligible Special Needs Plans

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.

  All-Inclusive Dual Eligible Special Needs Plans:

The All-Inclusive Dual (D-SNP) caters to beneficiaries who qualify for Medicare Advantage and are also eligible for Medicaid support through a State or Territorial plan. This type of D-SNP is inclusive, welcoming all dual eligible individuals, ranging from those with comprehensive Medicaid benefits to those receiving limited cost-sharing support.

  Comprehensive Benefit D-SNPs serve individuals eligible for:

Full Medicaid benefits for any given month under any eligibility category specified by the Medicaid State Plan, or comprehensive benefits through a demonstration under Section 1115 of the Act; or, Medical support under Section 1902(a)(10)(C) of the Act (for the Medically Needy) or Section 1902(f) of the Act (for states employing stricter eligibility criteria than the SSI program), provided the individual was eligible for medical support at any time during the month.

  Medicare Zero Cost-Sharing D-SNPs:

This D-SNP variant restricts its enrollment to Qualified Medicare Beneficiaries (QMBs) and QMBs receiving comprehensive Medicaid benefits (QMB+), which are the dual eligible beneficiary categories exempt from financial responsibility for Medicare Parts A and B cost-sharing. Notably, QMB-only individuals are not entitled to full Medicaid benefits and might incur Medicaid cost-sharing.

  Targeted D-SNPs / Medicare Zero Cost Sharing D-SNPs:

Targeted Dual Eligible D-SNPs may either incorporate cost sharing (Targeted Dual Eligible Subset) or exclude cost sharing (Targeted Dual Eligible Subset Medicare Zero Cost Sharing), providing flexibility in plan design to meet diverse beneficiary needs.

Authorized by the Affordable Care Act (ACA) in 2010, Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) represent a unique D-SNP aimed at seamlessly integrating Medicare and Medicaid services. FIDE SNPs, however, are available on a much more limited basis compared to other types.

FIDE SNPs are required to fulfill specific criteria, notably contracting with the state to offer Medicaid long-term care benefits and services in alignment with state policy through risk-based financing mechanisms. They are also tasked with coordinating the delivery of both Medicare and Medicaid health and long-term care services. Of all D SNPs, only 11 percent (45 out of 393 plans) qualify as FIDE SNPs. For additional information, refer to chap. 16b, section 40.4.3.

Upon submitting an enrollment request, the activation of the new coverage plan kicks in on the first day of the following month. According to CMS rules, the SEP's utilization is determined by the month in which the coverage change is elected. For example, if a choice is made in March for an April start date, the SEP for the first quarter is considered utilized, not the second quarter.

Furthermore, individuals experiencing changes in their Dual or LIS status—whether it's gaining, losing, or altering their eligibility—have a single chance to make a plan selection within three months of the change, or from when they're notified, whichever comes later.

For those who find themselves no longer eligible for Medicaid, an SEP window opens from the month they're informed about their ineligibility, extending an additional two months for them to choose a new plan.

Remember, eligibility for a Special Needs Plan is contingent on meeting specific criteria. Should an individual's circumstances change rendering them ineligible for their current plan, they're granted a Special Election Period. This allows them to either transition to a different Medicare Advantage plan or revert to Original Medicare.

Additionally, there's an SEP designed for individuals to revise their D-SNP once in each of the year's first three quarters. Navigating these options can be complex for your clients. Your role as a licensed agent in clarifying these choices is crucial, and it significantly influences the loyalty of your clients.

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.