About 12.5 million people in the U.S. have both Medicare and Medicaid. They’re known as “dual eligible.”

Dual Eligible Special Needs Plans (D-SNP) are special type of Medicare Advantage plans available for such people, offering more coverage than standard plans. We’ll break down what D-SNP is, how it works, and who it’s for, in simple terms.

D-SNP meaning: what are D-SNP Plans and how they work

Dual Eligible Special Needs Plans (D-SNP) are a type of Special Needs Plan (SNP) designed specifically for individuals who qualify for both Medicare and Medicaid. These plans are a type of Medicare Advantage plans that combine the benefits of Medicare and Medicaid programs, offering more comprehensive coverage than what you’d find in standard plans. Basically, a dual plan that offers Original Medicare as well as additional benefits at no extra cost.

Here’s a quick overview of how they work:

Integrated Coverage: D-SNPs merge the benefits of Medicare and Medicaid into one convenient plan. This means you get hospital and medical coverage, plus any additional Medicaid benefits, under one umbrella.

Personalized Care Coordination: Many D-SNPs offer care coordination services. This can include help from a care coordinator who assists in managing your healthcare needs, scheduling appointments, and ensuring you receive the right care at the right time.

Network of Providers: Like other Medicare Advantage plans, D-SNPs usually have a network of doctors and hospitals that you’re expected to use. It’s important to check if your current healthcare providers are in the D-SNP network.

D-SNPs come in three types:

• Coordination-only D-SNPs offer basic coordination between Medicare and varying state Medicaid services.
  
• Fully Integrated Dual-Eligible (FIDE) SNPs combine Medicare and most Medicaid services under one managed care organization. From 2025, enrollees must join both the FIDE SNP and its Medicaid plan.
  
• Highly Integrated Dual-Eligible (HIDE) SNPs are like Coordination-only but also have a Medicaid plan in the same areas. There’s no need for people to join both Medicare and Medicaid plans.

D-SNPs are not one-size-fits-all; they are designed to cater to the specific needs of their members. This means that the plan specifics can vary based on the population it serves, whether it’s people with certain chronic conditions, those with limited incomes, or individuals needing long-term care.

D-SNP vs C-SNP

Feature	D-SNP	C-SNP
Target Audience	People eligible for both Medicare and Medicaid	People with specific chronic conditions
Coverage	Combines Medicare and Medicaid benefits	Focused on managing chronic conditions
Eligibility	Must be eligible for both Medicare and Medicaid	Must have the specific chronic condition catered to by the plan
Focus	Broader coverage, including health, prescription drugs, and more	Specialized care and management for chronic conditions

D-SNP (Dual Eligible Special Needs Plans) are tailored for individuals who qualify for both Medicare and Medicaid and are designed to provide comprehensive health coverage by combining the benefits of both programs.

C-SNP (Chronic Special Needs Plans), also a type of SNP, is specifically for people with certain chronic or disabling conditions, like heart disease, diabetes, cancer, dementia, etc. These plans focus on providing specialized care and resources for managing these conditions. The emphasis is on personalized healthcare management, with services and provider networks dedicated to treating the specific chronic condition you have.

Features of D-SNP Plans

Dual Eligible Special Needs Plans (D-SNP) are a bit like an all-in-one healthcare package for people who qualify for both Medicare and Medicaid. Let’s break down what these plans typically offer:

Comprehensive health coverage

D-SNP plans typically provide complete coverage of Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). This includes:

• Hospital Stays: Covering inpatient hospital care, including semi-private rooms, meals, general nursing, and other hospital services and supplies;
• Medical Services: Including doctor visits, outpatient care, home health care, and preventive services like screenings and vaccines

Added Medicaid benefits

Since D-SNPs are for individuals who also qualify for Medicaid, they include extra benefits that Medicaid offers. These can vary by state but often include:

• Long-term care services
• Additional home and community-based services
• Lower or no cost-sharing for certain services

Care coordination

One of the notable features of DSNP medicare plans is the emphasis on care coordination. These plans often provide:

• Personal care managers or coordinators who assist members in navigating their healthcare needs
• Help with coordinating Medicare and Medicaid benefits
• Support for arranging transportation to medical appointments

Extra services

D-SNP plans may offer additional services not typically covered by Medicare or Medicaid, such as:

• Dental care, including exams, cleanings, x-rays, and sometimes more extensive dental work
• Vision care, including eye exams and eyeglasses
• Hearing services, including hearing aids

Flexibility and convenience

• No charge for monthly premiums as Medicare covers part of your medical bills first, and then Medicaid steps in to pay any leftover costs. Think of Medicaid as the backup payer for stuff that Medicare doesn’t fully cover.
• D-SNPs often offer more flexibility in choosing healthcare providers within their network
• Transportation to medical appointments
• They may also include extra conveniences like mail-order pharmacies and telehealth services

Do SNP Plans cover prescription drugs?

Yes, all D-SNPs provide prescription drug coverage, though formularies vary by plan. Many offer $0 copays on certain generic and brand drugs used to treat conditions like diabetes, lung disease, mental illness, and more. Any drugs not covered can usually be appealed on a case-by-case basis.

Who is eligible for D-SNP?

Eligibility for D-SNP hinges on a few criteria:

• You must be entitled to Medicare (Part A and B) and receive Medicaid benefits. You will have to prove that you have Medicaid by showing a card or letter from Medicaid. Note that every state has its own rules about who can get Medicaid (mostly low-income households) and what it covers. What you get with your plan can be different depending on where you live, but some plans cover everything that Medicare and Medicaid offer.
• SNP plans (and consequently D-SNP plans) aren’t available everywhere. You need to live in an area where a D-SNP plan is offered.
  Some D-SNPs cater to individuals with specific health conditions or circumstances.

Your eligibility for D-SNP isn’t set in stone. It can change, especially if your financial situation or health needs change. Most people go through a check each year to see if they still qualify.

D-SNP costs

There are different kinds of D-SNPs out there.

Some are HMO D-SNP, where you have a main doctor and a specific network, and others are PPOs, where you have more choice in doctors.

The kind of plan you get depends on the insurance company and where you live. Also, each plan might cost differently.

Moreover, with an SNP, your costs like premiums, copays, and deductibles are similar to those in standard Medicare Advantage plans, but they vary by plan.

In a D-SNP, these costs are lower because you qualify for extra help from federal and state governments due to your health, disability, or financial status.

Here’s a summary of the key cost elements:

• Prescription Drug Coverage: Many dual special needs plans offer $0 copays for covered prescriptions, reducing medication costs significantly.
• Healthy Options Allowance: This benefit in some plans helps cover various expenses and can roll over month-to-month within the plan year​​.
• MOOP Limits: In 2023, changes to the way Maximum Out-of-Pocket (MOOP) limits are calculated were introduced. These limits cap the total out-of-pocket costs for beneficiaries. After reaching MOOP, which is $8,850 for standard MA in-network plans in 2024, the plan pays 100% of Medicare Advantage costs. The new calculation method takes into account all cost-sharing in the plan benefit, whether paid by the beneficiary, Medicaid, or other secondary insurance, or remains unpaid. This change can potentially accelerate reaching the MOOP limit, after which Medicare covers 100% of Parts A and B coverage​
• Plan Type Variations: At the time of creation, each DSNP must identify whether it offers Medicare zero-dollar cost sharing or non-zero dollar cost sharing. This distinction can impact the amount of out-of-pocket expenses a beneficiary might incur​.
• Financial Impact of New Rules: Recent changes can influence supplemental benefits and premiums in DSNP plans​​.

D-SNP enrollment: when can you sign up?

You will not be automatically enrolled in a D-SNP because it is a type of Medicare Advantage plan. You can enroll in a D-SNP during:

• Open Enrollment Period which occurs annually from October 15th to December 7th, with coverage starting January 1st next year;
• Medicare Advantage Open Enrollment from January 1 to March 31 each year;
• Outside of the annual enrollment window, you can enroll in a DSNP during other Special Enrollment Periods if you experience certain qualifying life events like moving out of your current plan’s service area, losing Medicaid eligibility temporarily and then regaining it or transitioning from an institutional level of care like a nursing home to living in the community. You’ll need to contact Medicaid and enroll within 60 days of these events in order to change your DSNP for mid-year effective dates. It’s also possible for current DSNP members to switch to a new DSNP during this timeframe if their doctor leaves one plan’s network or they find another DSNP’s premiums to be a better fit financially.

To enroll in Medicare Advantage plans like D-SNPs, follow these steps:

• Find a plan in your area using Medicare’s plan finder tool for your ZIP code.
• You can enroll online or get a paper form to enroll by mail on the insurance company’s website for your chosen plan.
• If you need help, call 800-MEDICARE (800-633-4227).

D-SNPs: one-stop healthcare for many

In summary, D-SNP plans provide a comprehensive healthcare solution for those eligible for both Medicare and Medicaid.

By combining benefits from both programs, D-SNPs offer members expanded coverage and services at low costs. They coordinate care to make accessing healthcare easier through one coordinated system.

Check out your options during enrollment periods and see if a DSNP is the right fit for you. Here’s to making informed choices for your healthcare journey!