Dual-Eligible Special Needs Plans: Frequently Asked Questions

Table of Contents

Overview

This FAQ document answers common questions from advisors and advocates who are assisting individuals enrolled in both Medicare and Medicaid (“dually eligible individuals”) who are considering their health plan options. It is a companion to Justice in Aging’s brief Dual-Eligible Special Needs Plans: What Advocates Need to Know (“D-SNP basics brief”) and webinar.

What is a D-SNP?

Dual-Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage health plan designed to serve dually eligible individuals. D-SNPs are plans run by private insurance companies who contract with the Centers for Medicare & Medicaid Services (CMS) to provide Medicare (and sometimes Medicaid) benefits through managed care. All D-SNPs are required to coordinate an enrollee’s Medicare benefits with their Medicaid benefits to some level (see Question #8 for more information on integration requirements).

Are D-SNPs available in every state?

Currently, D-SNPs are available in 47 states and the District of Columbia (D-SNPs are not currently available in Alaska, New Hampshire, or Vermont). D-SNP availability depend in part on a person’s county or zip code. Individuals can see the D-SNPs available in their area by accessing the Medicare Plan Finder.

Enrolling in a D-SNP

Are dually eligible individuals required to join a D-SNP?

No. Dually eligible individuals can choose between Traditional Medicare (also often called original or fee-for-service Medicare), Medicare Advantage health plans, and (in most states) the Program of All-Inclusive Care for the Elderly program (PACE). Some states automatically enroll some dually eligible individuals into D-SNPs when they become Medicare eligible, but the right to opt out or disenroll remains. See Question #7 for more details on automatic enrollment.

Should a dually eligible person join a D-SNP?

The decision to join a D-SNP is an individual one based on a person’s health care needs and provider preferences, the D-SNP’s network of contracted providers, prescription drug availability, and other considerations. This can be a complicated choice. Speaking with a free, unbiased State Health Insurance Program (SHIP) counselor, reviewing plan materials, and using the Medicare Plan Finder are ways to help your client review their options and make the enrollment choice that is best for them.

Can a partial-benefit dually eligible person join a D-SNP?

A partial-benefit dually eligible individual is a person who is enrolled in a Medicare Savings Program (e.g., Qualified Medicare Beneficiary, Specified Low Income Medicare Beneficiary, or Qualified Individual) only and are not also enrolled in full Medicaid. Medicare Savings Programs are a type of Medicaid program that provides financial assistance by paying Medicare out-of-pocket costs including premiums, co-pays, and co-insurance. They do not provide the full range of Medicaid benefits, such as doctor visits, hospital stays, personal care services, long-term care in nursing facility, or other benefits.

A full-benefit dually eligible individual is a person who is enrolled in Medicare and full Medicaid, whether or not they are also enrolled in a Medicare Savings Program.

In most states, partial-benefit dually eligible individuals can enroll in a D-SNP (and in some of those states, separate D-SNPs are offered just for partial-benefit dually eligible individuals).¹

Each D-SNP is required to contract with the state in which it operates; this contract is called a State Medicaid Agency Contract (SMAC) and is sometimes public. A SMAC will contain information on which populations are eligible to enroll in a D-SNP. You can also contact your client’s state Medicaid agency or the plan to get clarity on D-SNP eligibility for partial-benefit dually eligible individuals

States determine which Medicaid enrollees are eligible for enrollment in a D-SNP. This includes whether a person who is medically needy (also known as “spend-down” or “share of cost”) is eligible for enrollment in a D-SNP. This information is sometimes available in a state’s SMAC. Advocates can find out more by contacting their client’s state Medicaid agency or the D-SNP.

If a person loses free Medicaid and is assessed a spend-down or share of cost, they will no longer be eligible for their D-SNP if full Medicaid is required for enrollment. D-SNPs in some states may have “deeming periods” that act as a short grace period keeping individuals enrolled in the D-SNP. This deeming period provides time for the individual to attempt to fix or restore their Medicaid eligibility. See Question #18 for more details.

Are people automatically enrolled into a D-SNP? What protections are available?

A person can be automatically enrolled in a D-SNP in some circumstances through “default enrollment.” People on Medicaid who become newly eligible for Medicare, either by age or disability, can be enrolled in D-SNPs through default enrollment. This is how it happens: A person enrolled in a Medicaid managed care plan when they become eligible for Medicare may be defaulted, or automatically, enrolled into the D-SNP that is affiliated with their Medicaid managed care plan. Plans must send written notice before automatic enrollment takes place and the person has the right to opt out. In order to opt out, your client must make the affirmative choice to cancel the default enrollment before it is effective.

Not all D-SNPs or states have default enrollment in place.² For more information on default enrollment, see Justice in Aging’s D-SNP basics brief.

Accessing information about D-SNP Integration and Responsibilities

How can a person find out what level of integration a D-SNP has?

Different types of D-SNPs have different levels of responsibilities when it comes to integrating Medicare benefits with Medicaid benefits, including care coordination, communications, and grievances and appeals. D-SNP categories are Fully Integrated (FIDE), Highly Integrated (HIDE), or coordination-only (CO D-SNP). Each of these categories can also have an Applicable Integrated Plan (AIP) designation. It is helpful to know what type of D-SNP a person is enrolled in to understand what responsibilities and coordination the D-SNP is obligated to provide to its enrollees. More information on these integration designations is available in Justice in Aging’s D-SNP basics brief.

It is not always easy to figure out a D-SNP’s integration level. Sometimes FIDE and HIDE designations are included in the plan’s name on Medicare Plan Finder or on the plan’s website materials (though often, these materials do not specify the type of D-SNP a plan is). You might consider calling the plan and asking about the plan’s integration level. CMS also releases Special Needs Plan (SNP) monthly data on Special Needs Plans. It is available as an excel document, and includes each plan name, the state it is in, and whether it’s a FIDE, HIDE, or CO D-SNP. Note that it may be hard to match the information from the Medicare Plan Finder to the SNP monthly data.

How can a person find state requirements for D-SNPs?

A state’s SMAC can contain a wealth of information, including eligibility criteria for enrollment into the D-SNP, extra care coordination requirements, and expectations around member communications. Some states publicly post their SMAC’s online but most do not. Accessing a state’s SMAC can be difficult. We’ve listed some examples of public SMACs in the Appendix. Advocates can try asking their Medicaid agency for a copy of their state SMACs. For more information on SMACs, see Justice in Aging’s D-SNP basics brief.

D-SNP Benefits, Provider Networks, and Costs

What benefits do D-SNPs offer?

D-SNPs are required to offer Medicare Part A (hospital/inpatient), B (outpatient), and D (prescription drug) benefits. D-SNPs often offer supplemental benefits that are not offered under Original Medicare, including vision, dental, hearing, transportation, and flex cards. Please note that Medicaid often covers many items that are also offered as supplemental services by a D-SNP. D-SNPs plan materials, including the Evidence of Coverage, will list the services offered by the D-SNP.

One thing to look out for is whether the client’s provider or supplier is enrolled in the D-SNP, which can affect whether Medicare or Medicaid will cover the service. See Question #14, below, for more information about available providers.

What care coordination will a D-SNP offer?

D-SNPs must follow their model of care, which must include a description of how the D-SNP will coordinate care for enrollees.³ A state’s SMAC may include additional care coordination requirements, including requirements for the D-SNP to engage in discharge planning from a hospital or nursing facility say, and to incorporate additional elements in its health risk assessment for the individual. The Integrated Care Resource Center recently published sample care coordination language it found in various state SMACs.

Plan materials (including the Evidence of Coverage) may, but do not always, contain information on the care coordination offered by a plan. Advocates can try contacting their client’s state Medicaid agency to obtain additional information about care coordination offered by D-SNPs.

What costs are associated with a D-SNP?

In general, a dually eligible person should not be charged premiums, co-pays, or co-insurance, in Traditional Medicare or in a D-SNP. In certain circumstances, a D-SNP may charge an additional premium for offering additional services. If an individual accesses non-covered services, or goes to a provider that is not enrolled in Medicare or Medicaid, there may also be associated costs.

Providers sometimes charge dually eligible individuals for services improperly. For more information, see Justice in Aging’s Improper Billing Toolkit.

Does your client have to get prior authorization from a D-SNP?

Yes, your client may need to get prior authorization, depending on the service they are seeking. Prior authorization, or prior approval, is an element of a D-SNP. Members must get prior authorization from the D-SNPs for many health services before treatment is provided. A plan’s Evidence of Coverage can include information on which services may be subject to prior authorization.

One thing to look out for when switching plans is whether a prior authorization approval will follow your client to the new plan, and how long it will last. In some circumstances, the approval can stay in place for months after the switch.

What health care providers are available in a D-SNP?

One key difference between Traditional Medicare and a D-SNP is that enrollees are required to see providers that are contracted with the health plan or agree to accept payment from the plan. The D-SNP provider directory will include the list of providers members can see for their care. The directory is also available on the plan’s website or in print.

It can be the case, however, that the provider directory is out of date, or that listed providers are not accepting new patients. For providers that are important to a client, it might be a good idea for them to contact that provider before switching plans.

What medications does a D-SNP cover?

Medicare Plan Finder includes a tool which allows individuals to enter in the medications that they would like their plan to cover. They can then search D-SNPs to find their medications and network pharmacies. A D-SNP’s Part D formulary is also listed online. 1-800 Medicare and SHIP counselors are also a good resource to determine which D-SNPs include coverage for their prescription drugs.

How will enrolling in a D-SNP affect a person’s Medicaid benefits?

A person will continue to keep their Medicaid benefits while enrolled in a D-SNP. Some D-SNPs, such as FIDE SNPs, may include coverage and delivery of Medicaid benefits. All D-SNPs are required, at some level, to coordinate their enrollee’s Medicaid benefits. Appendix B of Justice in Aging’s D-SNP basics brief provides a table explaining how different kinds of D-SNPs are required to offer different types of Medicaid benefits.

One thing to look out for when considering a client’s enrollment into a D-SNP is when a client is enrolled in 1915(c) home and community-based services (HCBS) waiver. Some states and D-SNPs restrict enrollment for people who are enrolled in 1915(c) HCBS waivers. Advocates should confirm with the D-SNP or state so that their clients do not inadvertently jeopardize their 1915(c) services by joining a D-SNP.

Leaving a D-SNP

How can a person leave a D-SNP?

There are many times of year that a dually eligible individual can leave a D-SNP:

Anyone can leave a Medicare Advantage plan, including a D-SNP, from January through March each year.
Dually eligible individuals have an option, once per quarter, to disenroll in a D- SNP and join Traditional Medicare (including enrolling in a Part D plan). You can find out more information about options to disenroll from or change Medicare Advantage Plans on this CMS website. Starting in January 2025, dually eligible individuals will have an option to disenroll on a monthly (rather than quarterly) basis in certain circumstances.
Since D SNPs are a type of Medicare Advantage plan, other Special Enrollment Periods around disenrolling from or switching Medicare Advantage plans can apply.

Are their situations where a person loses membership in a D-SNP? What protections are available?

A person can be disenrolled from the D-SNP if they no longer meet the enrollment criteria. This includes moving to a service area not covered by the D-SNP or if Medicaid benefits are discontinued. Some D-SNPs offer a “deeming period,” which maintains D-SNP enrollment if a person loses full Medicaid. A person is “deemed” eligible for a temporary period of time. Deeming periods can last thirty days to six months, depending on the plan. Deeming provides continued access to D-SNP providers and D-SNP provided care. If a person restores their Medicaid eligibility before the deeming periods ends, they will not be disenrolled.

Deeming is optional and not all states or D-SNPs have deeming periods. Medicaid benefits may not be covered during the deeming period. To find out if deeming is offered, enrollees can ask their D-SNP if they offer a deeming period and for how long. The State SMAC, if publicly available, will also contain this information if a D-SNP offers deeming.

Appendix: Examples of Public State Medicaid Agency Contracts

Each D-SNP sponsor must enter into a contract with the state in which the D-SNP operates. These contracts are called State Medicaid Agency Contracts (SMACs). Below is a sample of SMACs that are public. Many of these SMACs were collected by the Integrated Care Resource Center. For more information about topics that SMACs address, see the ICRC’s resource on sample SMAC language.

The SMACs listed below may not be the most up to date versions available.