Roughly 12.5 million Americans have both Medicare and Medicaid coverage.1 These people are referred to as “dual eligible.” If you’re one of them, you have several options for coordinating your coverage and care. One choice is having original Medicare with separate coverage through Medicaid. However, you can also choose to enroll in a Dual Eligible Special Needs Plan (D-SNP) if one is available in your area.
What is a Dual Eligible Special Needs Plan?
First, it helps to be familiar with a Medicare Special Needs Plan (SNP)—a type of Medicare Advantage (Part C) plan that offers broader Medicare coverage to a specific, limited population. SNPs are tailored to meet the needs of their members, which is typically people with:
- Low income
- Certain medical conditions
- Unique health care requirementsÂ
A Dual Eligible Special Needs Plan is one type of SNP. It’s a managed care plan for people who qualify for both Medicare and state Medicaid assistance or Medicaid. A D-SNP combines multiple coverages and coordinates Medicare and Medicaid benefits to make them easy to access for people who have both. States decide which D-SNPs health plans can offer and may review the specific benefits provided.
Dual eligible people fall into several Medicaid eligibility categories. This determines the type of D-SNP plan you can enroll in, your access to Medicaid benefits, and the level of help you can receive for premiums and cost sharing. States may set up their eligibility categories differently, so be sure to check with your state before enrolling in a plan.
What’s the difference between a D-SNP and a C-SNP?
Like a D-SNP, a Chronic Condition Special Needs Plan (C-SNP) is a type of SNP. While D-SNPs are for people with both Medicare and Medicaid eligibility, C-SNPs are designed for people who have a specific chronic or disabling condition (e.g., diabetes or heart disease). C-SNP members may have access to a network of providers who specialize in their condition and better coverage for prescription drugs used to treat their condition.
Do I qualify for a D-SNP?
If you qualify for both Medicare and Medicaid, you most likely qualify for a D-SNP. An easy way to determine if you are dual eligible is to check that you have a Medicare card and a Medicaid card.
In general, you must:
- Be a U.S. citizen or a lawful, permanent resident
- Qualify for original Medicare (Parts A & B)
- Meet the income and asset requirements for your state's Medicaid program
- Live in a service area where D-SNPs are available
There may be other rules for enrollment, depending on the plan you choose. Be sure to check with the plan provider for details.
Does a D-SNP offer both Medicare and Medicaid coverage?
Like all Medicare Advantage plans, D-SNPs are required to cover everything original Medicare (Parts A and B) covers. You also have access to full or partial Medicaid benefits, depending on your Medicaid eligibility category.
D-SNPs allow you to keep your Medicaid benefits while providing additional support to deal with your health care needs. You don’t have to worry about losing your Medicaid eligibility by enrolling in or using your D-SNP benefits.
What are the benefits of a D-SNP?
A D-SNP supports the needs of members who have both Medicare and Medicaid, with the goal of improving care quality and efficiency. Below are some of the plan’s key advantages:
- Since members who qualify often have the greatest needs, D-SNPs tend to offer the most in-depth set of health benefits among all Medicare plans.
- D-SNPs can provide a more streamlined, hassle-free experience in using your benefits. This is because you’re receiving coverage from a plan that helps arrange services on your behalf. The plan's team members understand the differences in Medicaid and Medicare coverage.
- D-SNPs often offer extra benefits beyond what you can get from original Medicare and Medicaid. These benefits can fill gaps in your care and improve your quality of life. Some examples include:
- Dental coverage
- Gym memberships
- Eyeglasses and hearing aids
- Allowances for healthy foods and over-the-counter products, or even gasoline
- Transportation assistance
- Meal delivery
- A personal care team
One of the biggest benefits of a D-SNP is that it often comes with a care coordinator," said Laura Esslinger, vice president of Medicare Duals segment for Aetna.
"These professionals are employed by the plan to make sure members get the right care and information. They can help you find in-network doctors and specialists, schedule medical appointments, arrange for transportation and facilitate access to care and benefits," Esslinger explained. Â
A D-SNP may be a good fit if you are looking for the highest level of benefits. You should also be comfortable with managed care and using providers within a defined service network.
Will a D-SNP cover my prescriptions?
Yes. Since SNP members have unique financial and health care needs, all SNPs must include Part D prescription drug coverage.
What are the costs to me for a D-SNP?
Medicare Advantage plans typically include some cost sharing in the form of premiums, copayments, coinsurance, and deductibles. But since a D-SNP qualifies members for additional support, most people pay little to no out-of-pocket costs under this plan. Your level of cost sharing depends on your category of Medicaid eligibility.
Medicare pays its portion first, and then Medicaid (known as the second payer) takes care of any remaining costs. This system was created to help people with the greatest needs keep their health care spending down.
When can I enroll in a D-SNP?
You must be enrolled in original Medicare before joining a Medicare Advantage D-SNP. Typically, you have several chances to enroll if you qualify:
- Initial Enrollment Period: This is the 7-month period starting three months prior to the month in which your 65th birthday takes place.
- General Enrollment Period: This period runs from Jan. 1 to March 31 of each year. During this time, you can sign up for Medicare Parts A and B if you did not enroll when you first became eligible. You can then sign up for Medicare Advantage in April through June.
- Open Enrollment Period: This period runs from Oct. 15-Dec. 7 each year. You can pick a new Medicare Advantage plan, switch from original Medicare to Medicare Advantage, or change your Part D coverage.
- Special Enrollment Period: This period may be triggered by a qualifying life event — such as moving out of your current plan's service area or becoming eligible for Medicaid benefits.
If your situation changes while you’re enrolled in a D-SNP and you lose your eligibility, you will have a Special Enrollment Period to disenroll. Then, you can either join a regular Medicare Advantage plan or reenroll in original Medicare.
The best way to choose a Medicare plan is to explore all the coverage options available to you. Learn how you can connect with a licensed Medicare advisor who can help you find the plan that best meets your health care needs, budget, and lifestyle.
This content was developed in partnership with Aetna. Learn more about what you need to know about Medicare.
Sources
1. Kaiser Family Foundation. Medicare. A Profile of Medicare-Medicaid Enrollees (Dual Eligibles). Jan. 31, 2023. Found on the internet at https://www.kff.org/medicare/issue-brief/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/
