Key Takeaways

  • Dual-eligible special needs plans (D-SNPs) are Medicare Advantage plans specifically for people who qualify for both Medicare and Medicaid. The plans help them to reduce their out-of-pocket healthcare expenses.
  • D-SNPs offer comprehensive coverage, and may include care coordination, prescription drugs, over-the-counter medications, transportation, telehealth, vision, hearing, and fitness benefits, with Medicare and Medicaid covering most or all costs.
  • Eligibility for D-SNPs requires enrollment in Medicare parts A and B, with plan availability and specific coverage varying by state and the insurance company administering the plan.

If you are age 65 or older, have specific health conditions, and a limited income and resources, you may be eligible for both federal and state health insurance programs.

A total of 12 million people are considered “dually eligible” for and enrolled in both Medicare and Medicaid coverage based on their age and health conditions.

If you are dually eligible, you may qualify for a dual-eligible special needs plan, or D-SNP.

D-SNPs are Medicare Advantage plans that cover all the services that many other Medicare Advantage plans offer, plus some others. These include:

With most Medicare Advantage plans, you pay a portion of your plan cost out of pocket. With a D-SNP, Medicare and Medicaid will pay most or all of your costs.

Medicare pays for a share of your medical costs first, then Medicaid pays any eligible expenses that may be left over. In this instance, Medicaid is the second payer for costs that are not covered or only partially covered by Medicare.

Generally, your D-SNP premiums will depend on the specific plan, but some may have $0 monthly premiums.

What is the difference between SNP and D-SNP?

A Medicare special needs plan (SNP) is another type of Medicare Advantage (Part C) plan that provides extended Medicare coverage. These plans help coordinate care and benefits based on your needs. There are three types of SNPs:

  • dual eligible (D-SNP)
  • chronic condition (C-SNP)
  • institutional (I-SNP)

D-SNPs are one of the most complex SNPs in terms of coverage and eligibility requirements.

However, they also offer the most comprehensive benefits because those who qualify typically have the highest care needs.

Some SNPs require you to pay a share of the plan costs, similar to that of any Medicare Advantage plan. Premiums, copayments, coinsurance, and deductibles can all vary depending on your chosen plan.

However, with a D-SNP, your costs are lower because your health, disability, or financial situation has qualified you for additional support from federal and state governments.

According to an analysis by Justice in Aging, D-SNPs are closely monitored and regulated by the federal government for more than their cost benefits. These plans must follow an approved care model, work with Medicaid benefits, and undergo monitoring by an advisory committee.

States also have a say in how these plans operate, which means there are different types of plans depending on how integrated they are with Medicaid in each state. The more integrated they are, the more comprehensive and coordinated your healthcare services might be.

Like other Medicare Advantage plans, D-SNPs may cover additional services beyond what’s covered by Original Medicare, such as dental care. The Centers for Medicare & Medicaid Services (CMS) requires that if Medicare or Medicaid could potentially cover a service, the plan must review it using criteria from both programs.

This means that if your plan doesn’t cover something and you appeal it, the plan will have to conduct a comprehensive review and may reconsider your request.

While federal law sets Medicaid income standards, each state has its own Medicaid eligibility and coverage limits. Plan coverage varies by state, but some include all Medicare and Medicaid benefits.

To be considered for any of the SNPs, you must first be enrolled in Original Medicare parts A and B, which cover inpatient hospital care and outpatient medical services.

There are various D-SNPs available. Some are Health Maintenance Organizations (HMOs), and some may be Preferred Provider Organizations (PPOs). The plans and their costs differ based on the insurance company you choose and the area in which you live.

You can call Medicare at 800-633-4227 (TTY: 877-486-2048) for more information or to ask questions about D-SNPs and other Medicare benefits.

Qualifying for Medicare

You are eligible for Medicare once you turn age 65. You can enroll 3 months before your 65th birth month, throughout your birth month, and for 3 months after.

You are also eligible for Medicare, regardless of age, if you have a qualifying health condition or disability, such as end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), or if you have been receiving Social Security Disability Insurance (SSDI) for 24 months or more.

If you are eligible, you may enroll in a D-SNP during an appropriate Medicare enrollment period if D-SNPs are available in your area.

Qualifying for Medicaid

Medicaid eligibility is based on several factors, including income, health conditions, and whether you qualify for Supplemental Security Income (SSI).

You can contact your state’s Medicaid office to find out if you’re eligible for Medicaid coverage where you live.

When you turn 65, you may be automatically enrolled for Medicare parts A and B. However, you won’t be automatically enrolled in a D-SNP because it is a type of Medicare Advantage plan which private insurance companies administer.

You may enroll in a Medicare Advantage plan, including a D-SNP, during Medicare’s enrollment periods, which include the:

  • Medicare Advantage open enrollment period, which runs from January 1 to March 31 each year
  • open enrollment period, which runs from October 15 to December 7
  • special enrollment period, which varies depending on your circumstances

To enroll in any Medicare Advantage plan, including D-SNPs, you can:

  • Choose a plan in your area by using Medicare’s plan finder tool. This will show available plans in your ZIP code.
  • Enroll by mail if you know the insurance company you would like to use and have looked into their plan options. You can visit their website or call them directly to download or request a paper form.
  • Call Medicare at 800-633-4227 (TTY: 877-486-2048) to discuss plan options.
Documents you will need to enroll in a D-SNP
  • your Medicare card
  • the specific date you enrolled in Medicare parts A and/or B
  • proof of Medicaid coverage (your Medicaid card or an official letter)

If you have extensive health needs or disabilities and your income is limited, you may qualify for both federal and state support.

Dual-eligible special needs plans (D-SNPs) are a type of Medicare Advantage plan that covers your hospitalization, outpatient medical care, and prescriptions. Federal and state funds cover some or all of the plan’s costs.

If you qualify for both Medicare and your state’s Medicaid program, you may be entitled to low- or no-cost healthcare under a D-SNP.