A Dual Eligible Special Needs plan provides special coverage for a person who is eligible for both Medicare and Medicaid.
The plan is one of several Special Needs plans (SNPs), which are a type of Medicare Advantage plan for people who qualify for state and federal public health insurance programs. Not all states offer the plans.
This article explains Dual Eligible Special Needs (D-SNPs) and discusses other SNPs. It also looks at SNP eligibility, enrollment, and costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
According to Medicaid, 12 million people in the United States are eligible for both Medicare and Medicaid coverage and qualify for SNPs.
SNPs customize benefits, health provider lists, and drug formulary to meet specific needs. They generally provide comprehensive coverage.
A D-SNP is a comprehensive plan, available only to a person who is eligible for both Medicare and Medicaid.
Medicare SNPs provide similar coverage to Medicare Advantage plans, including Part A hospitalization, Part B outpatient medical services, and Part D drug prescriptions.
SNPs may also cover extra services customized to the groups they serve, such as coverage for extra days in the hospital. Some SNPs offer additional benefits such as dental, vision, and hearing care.
Before choosing an SNP, a person might want to check on the services and benefits of each plan.
Factors to check may include:
- Does the D-SNP organize a person’s Medicare and Medicaid benefits to allow easy access?
- How do SNP services compare with those offered through a person’s current plan?
- What benefits does the SNP provide that will assist with special health needs?
- Does the plan cover specialists?
- What are the costs for premiums, deductibles, and copays?
- Is there a yearly limit for out-of-pocket expenses?
- Can a person use their current doctor?
- Does the plan provide coverage for services from out-of-network providers?
- Does a person need a referral to see a specialist?
- Are a person’s prescription drugs listed on the plan formulary?
A person can call or use this online tool to check for plans available in their area.
To join a D-SNP, a person must be enrolled in both Medicare and Medicaid.
A person can check if they are eligible for Medicaid through the Medicaid office in their state.
In general, a person can enroll in an SNP if they meet certain conditions:
- have original Medicare (Part A and Part B)
- live in the plan service area
- have specific disabling or severe chronic conditions, including autoimmune disorders, end stage renal disease, or chronic lung disorders
A person may also qualify for an SNP if they need nursing care at home, live in a care home, or are enrolled in both Medicare and Medicaid. A person can check the complete list of qualifying conditions online.
SNPs may not be available in all states, and a person can use this online tool to check plan details and availability in their area.
A person can enroll in SNPs, including D-SNPs, during the following Medicare enrollment periods:
- From January 1 to March 31
- During Open Enrollment Period (OEP) from October 15 to December 7
- In the Special Enrollment Period (SEP) if there is a change in a person’s circumstances, such as moving to live in a different area.
When a person has chosen a plan, they can call the plan provider for an online or paper enrollment form. They can also call Medicare for assistance at 800-MEDICARE (800-633-4227).
Medicare SNPs are required to offer the same benefits as original Medicare but may do so with separate rules, restrictions, and costs.
For example, an SNP may charge a monthly premium in addition to the monthly Part B premium. Each plan also specifies its copays, deductibles, and related cost-sharing for services.
If a person is enrolled in a D-SNP, most of the costs are covered by Medicare and Medicaid. A person does not generally have to pay a Medicare deductible or copay when they visit a health provider within the D-SNPs network.
Depending on the SNP, a person may also have coverage for out-of-network healthcare, although they may pay more for out-of-network services.
While SNPs cannot charge more than original Medicare for specific types of care, including chemotherapy, dialysis, and skilled nursing facility care, there may be additional costs for other services, such as durable medical equipment, home health, and inpatient hospital care.
Some SNP providers may help a person get the correct information, benefits, and services through a care coordinator.
Special Needs plans (SNPs) are a type of Medicare Advantage plan, and include a Dual Eligible Special Needs plan (D-SNP).
A person can join an SNP if they have Medicare Part A and Part B, live in the plan service area, and have one or more of covered chronic health conditions.
Coverage is comprehensive, although costs may vary between SNP plans, including in a D-SNP.