EVERYTHING YOU NEED TO KNOW ABOUT MEDICARE D-SNPs

The Medicare Annual Enrollment Period runs from October 15 to December 7 every year.

This is a time when people aged 65 and older can review their health coverage and decide if they want to make changes for the next year, like switching to a new Medicare Advantage plan, or seeing if a D-SNP (Dual Special Needs Plan) might be a better fit if they have both Medicare and Medicaid.

What is a D‑SNP?

A D-SNP (Dual Eligible Special Needs Plan) is a special kind of Medicare Advantage plan that combines both Medicare and Medicaid so it’s easier to get the care and help you need.

With a D-SNP, Medicare helps pay for things like hospital stays, doctor visits, and sometimes medicines. Meanwhile, Medicaid helps with other costs that Medicare doesn’t fully cover, like extra care or help at home (this depends on the state you live in).

Defining Features of a D-SNP

• D‑SNPs are private plans. They are run by private insurers approved by Medicare, but are tailored for dual eligibles.
• They combine or coordinate benefits from Medicare and Medicaid to reduce gaps (e.g. out‑of‑pocket costs) and improve care coordination.
• They always include Medicare Part D (prescription drug coverage).

Purpose of D-SNPs

Many people who have both Medicare and Medicaid have serious or long-term health problems. They often need help from different doctors and health services. But using two programs can be confusing and hard to manage. Some common problems include:

• Medicare and Medicaid not working well together
• Not knowing which program pays for what
• Still having to pay some costs, like copays or deductibles
• Missing coverage for things one program covers, but the other doesn’t

D-SNPs are made to help with these problems. They try to:

• Coordinate care between Medicare and Medicaid
• Lower costs for the person
• Add extra benefits, like help managing health problems or getting rides to appointments

This makes it easier for people to get the care they need without stress and confusion.

Who Can Get D-SNPs

Not everyone gets the same help from Medicaid, and the kind of help you get may vary depending on where you live. For example, someone in Arizona might get different benefits than someone in California.

There are two main types of people who qualify for dual eligibility, or coverage from both Medicare and Medicaid.

1. Full Duals (Full Benefit)

• You get full Medicaid benefits
• Medicaid helps pay for things that Medicare doesn’t, like:
  • Monthly premiums
  • Co-pays and deductibles
  • Extra support like help at home

• You usually get more services and lower costs

2. Partial Duals

• You get some help, but not full Medicaid benefits
• Your state might help pay your Medicare premium or some copays,
  but not cover extra medical services

The type you are — full or partial — is a deciding factor in which D-SNPs you can join.

• Some D-SNPs only take people with full benefits
• Others may allow partial duals, but the coverage might be different, and you might have to pay more

What Benefits Do D-SNPs Offer?

A D-SNP has to cover everything that Original Medicare covers, which includes:

• Hospital care (Part A)
• Doctor visits and medical care (Part B)
• Prescription drugs (Part D)

Additional benefits you might get are:

• Help Coordinating Care: You may get a care manager or helper who guides you through your healthcare and other services you need.
• Extra Benefits: These can vary depending on the plan and your state, but might include:
  • Dental care
  • Vision care (like glasses)
  • Hearing aids
  • Rides to doctor appointments
  • Telehealth (talking to doctors on the phone or computer)
  • Over-the-counter medicines and supplies
  • Fitness programs
  • Help at home or with long-term care services
• Lower Costs: Because Medicaid helps out, many D-SNPs have lower or no monthly fees, and you might pay less for visits, medicines, and other services.
• Simpler Appeals and Complaints: If you have a problem with your coverage or need to appeal a decision, D-SNPs often have combined rules for Medicare and Medicaid to make it easier to fix problems.
• More Chances to Join or Switch Plans: People with Medicaid and extra help can often switch plans or join at special times, making it easier to find a plan that works best for them.

Who Can Join a D-SNP?

To join a D-SNP, you must:

1. Have Medicare: You must already be signed up for Medicare Parts A and B.
2. Have Medicaid: There are two types of Medicaid help, full and partial. What kind of Medicaid you can get depends on your state laws.
3. Live where the plan is offered: D-SNPs are only available in certain states or counties.

Note: Some D-SNP plans only take people with full Medicaid, while others accept those with partial Medicaid.

Recent changes are making these enrollment options even more flexible for dual eligible individuals in many cases.

Advantages and Disadvantages of D-SNPs

Like any health plan, D-SNPs have some pros and cons. Whether it’s a good fit depends on your health, where you live, and what you need.

Advantages

• Helps Save Money: Many D-SNP plans have low or no monthly costs, low copays, and no big bills. Medicaid can help pay for things that Medicare doesn’t cover.

• Helps with Your Care: Some D-SNP plans give you a care manager. This is someone who helps schedule doctor visits, and checks in on your health, enabling you to stay healthier and avoid problems.
• Extra Benefits: D-SNPs often give extra things you don’t get with regular Medicare, like:
  • Glasses or eye exams
  • Hearing aids
  • Dental checkups
  • Free rides to the doctor
  • Money for over-the-counter (OTC) items

• Easier to Understand Your Coverage: With a D-SNP, your Medicare and Medicaid work together in one plan. That means:
  • Less paperwork
  • Fewer billing surprises
  • Not having to figure out which plan covers what since everything is in one place.

Possible Downsides of D-SNPs

A few things to watch out for, are:

• Fewer Doctors to Choose From: Some D-SNPs only let you go to certain doctors or hospitals that are in their network. If your favorite doctor isn’t in that network, you might have to pay more, or they might not be covered at all.

• Plans Are Different in Each State: Medicaid is run by each state, so the rules and benefits change depending on where you live. A D-SNP in one state might be very different from one in another state. This can make it hard to compare or know what to expect.

• It Can Still Be Confusing: Even though D-SNPs try to make things easier, having both Medicare and Medicaid can still make it tricky to understand:
• What’s covered
• What you have to pay
• Which doctors you can see

If you make a mistake (like seeing a doctor who’s not in your plan), you might get a surprise bill.

• Not Every Area Has D-SNPs: Some places, such as rural areas or smaller towns, don’t offer D-SNPs at all, or there might be only one or two choices. Also, if you move, your plan may not work in your new area.

• Plans Can Change Every Year: D-SNPs sometimes change their rules, benefits, or costs each year because of new government policies. A plan you like this year might not be the same next year. It’s important to check your plan every year so you don’t miss anything important.

How to Pick the Right D-SNP Plan

If you or someone you help is thinking about joining a D-SNP (Dual Special Needs Plan), here are some things to check before choosing a plan:

• Do You Qualify? Make sure the plan accepts people with your type of Medicaid.
  Some plans only take people with full Medicaid, while others take people with partial Medicaid, too.
• What’s Covered? Look at the extra benefits. Does the plan offer:

• Glasses
• Hearing aids
• Dental care
• Rides to the doctor

Also, check if the plan has the services and doctors you need.

• How Much Will It Cost You? Ask:
  • Do I have to pay a monthly fee?
  • What are the copays (the small amounts you pay at the doctor)?
  • Is there a deductible (money you must pay before the plan helps)?
  • Are there plans with no costs for Medicare services?

Some D-SNPs have ‘$0 cost sharing’, which means you might not have to pay anything for certain services.

• Can You Keep Your Doctors? Check if your current doctors and hospitals are in the plan’s network. If you need a specialist, home care, or nursing home care, make sure those are covered too. Also, if you move or travel, see if the plan still works in other places.
• How Well Do Medicare and Medicaid Work Together in This Plan? Some D-SNPs are very well combined, which means fewer problems and less confusion. These are called:
  • FIDE-SNPs (Fully Integrated)
  • HIDE-SNPs (Highly Integrated)

The more integrated the plan is, the easier it is to manage your care.

• Can You Switch Easily if Needed? Ask what the rules are for switching plans. Some people can change at any time. Others must wait for a certain time of year.
• Is the Plan Any Good? Look at the plan’s Medicare star rating (1 to 5 stars). More stars mean better care, good customer service, and fewer problems with billing or appeals
• Does it Work in Your Area? Every state has different Medicaid rules, so check if the plan follows your state’s rules.

Frequently Asked Questions about D-SNPs

1. Do I have to enroll in a D‑SNP if I qualify?
   No. Dual eligibility gives you more options, but you are not required to enroll in a D‑SNP. You can stay in Original Medicare plus Medicaid, or choose another Medicare Advantage plan (if available) or a stand‑alone drug plan, depending on your circumstances.

2. Does the D‑SNP replace Medicaid?
   No. Medicaid is still in place for dual eligibles; what the D‑SNP does is coordinate benefits between the two. Medicaid usually still helps with additional benefits and costs that Medicare doesn’t cover. But you may be required (or find it simpler) to use providers that accept both Medicare and Medicaid or are in the plan’s network.

3. Will I lose access to certain providers or services?
   Possibly, if your providers are outside the plan’s network. That’s why checking networks is important. Plans that are more integrated may have narrower networks in exchange for more convenience/cost savings.
4. Are there income or residency rules beyond just being dual eligible?
   Yes. Medicaid eligibility is governed by state rules — counting income, assets, residency, citizenship or immigration status, etc. Those rules affect whether you are full dual, partial, or not eligible. Also, whether you live in the service area of the plan is key.

Who Should Consider a D‑SNP?

A D‑SNP may be a good option if you or someone you assist:

• • Has both Medicare (Parts A and B) and qualifies for Medicaid in your state
  • Needs support managing multiple chronic conditions or complex care
  • Has difficulties covering out‑of‑pocket costs under standard Medicare
  • Is interested in extra benefits (dental, vision, hearing, transportation, etc.) that are not well covered under Original Medicare or standard MA plans
  • Could benefit from having one coordinated plan for both Medicare and Medicaid rather than dealing with two completely separate benefit systems

On the other hand, if your doctors are not in the plan’s service network, or you prefer more provider flexibility than the network allows, then a D‑SNP may be less attractive.

How to Enroll or Change Plans

If you are considering enrolling in a D‑SNP (or changing from one to another):

1. Check if one is offered in your area: Use Medicare.gov or state Medicaid websites to see what D‑SNPs are available in your county. Make sure you live in the plan’s service area.
2. Confirm your dual eligibility status: Find out if you are full dual eligible or partial, or eligible through a savings program. Knowing which benefits you receive from Medicaid helps in understanding what the plan will cover.
3. Compare plan offerings: Compare premiums, cost sharing, extra benefits, provider network, and whether the plan is a more integrated type (FIDE‑SNP) or otherwise aligned with Medicaid. Use the Medicare Plan Finder tool or get help from a counselor.
4. Look up enrollment windows: See whether you are in your Initial Enrollment Period, or the Annual Election Period, or if a Special Enrollment Period applies (if your Medicaid eligibility changed, you moved, etc.).
5. Check plan quality and ratings: Review star ratings, especially regarding care coordination, customer satisfaction, and how the plan handles appeals and grievances.
6. Enroll: Once you pick a plan, you can enroll via Medicare.gov, by phone, or via the plan directly.

Rules and Policies That Matter for D-SNPs

There are some important rules and systems that help D-SNPs work the right way. Here’s what to watch for:

• State Contracts: Every D-SNP must have a contract with the state’s Medicaid program. This contract explains how the plan will:
  • Share information
  • Work together on billing and services
  • Handle complaints and appeals

• Star Ratings: Medicare gives each D-SNP a star rating (from 1 to 5 stars). Plans with better care, happier patients, and fewer hospital stays get more stars.

• Money and Payments: How much money a D-SNP gets from Medicare and Medicaid affects how well they can help members. Payments may change based on:
• The health needs of the people they serve (called risk adjustment)
• State and federal rules
• Changing Health Needs: As more people get older or live with chronic conditions, more people may need D-SNPs. That means the government needs to keep updating the rules to make sure the plans can handle more people and provide good care.

What You Should Do Now

If you (or someone you help) may be eligible:

• Get clear documentation of your Medicaid eligibility and what benefits Medicaid provides for you.
• Make a list of your health needs (e.g. specialist care, chronic conditions, transportation, vision, hearing, etc.).
• Find out which D‑SNPs are offered in your area and compare plans side by side.
• Check your current providers and see whether they are in‑network for the D‑SNPs you are considering.
• Check total cost, not just premiums: copays, deductible, cost sharing, etc.
• Don’t forget about extra benefits — sometimes the ‘extras’ make a big difference.
• Use help: State Health Insurance Assistance Programs (SHIPs), Medicaid offices, Medicare.gov, community organizations.