A Medicare Dual Eligible Special Needs Plan (D-SNP) is a special Medicare Advantage plan for people eligible for both Medicare and Medicaid. The plans can help with high out-of-pocket costs.

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

Experts report that 12 million people are eligible for and enrolled in both Medicare and Medicaid coverage based on their age and health conditions. If you’re one of them, you may qualify for a D-SNP.

D-SNPs are Medicare Advantage plans that cover all the services that many Medicare Advantage plans offer. 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 costs 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 premium will depend on the specific plan, but some may have $0 monthly premiums.

What is the difference between SNP and DSNP?

A Medicare special needs plan (SNP) is a 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
  • chronic condition
  • institutional

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 needs.

Some SNPs require you to pay a share of the plan costs, similar to that of any Medicare Advantage plan. Plan premiums, copayments, coinsurance, and deductibles can 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 the 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 be monitored 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 (HMO), and some may be Preferred Provider Organizations (PPO). The plans differ based on the insurance company you select and the area where you live. Each program may have different costs.

You can call 800-633-4227 for more information or to ask questions about D-SNPs and other Medicare benefits.

Qualifying for Medicare

You are eligible for Medicare starting at age 65. You can enroll 3 months before your 65th birth month, through your birth month, and for 3 months after.

You are also eligible for Medicare, regardless of age, if you have a qualifying 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, and these plans are administered by private insurance companies.

You may purchase Medicare Advantage plans, including D-SNPs, during Medicare’s enrollment periods, which include:

  • Medicare Advantage open enrollment period, which runs from January 1 to March 31 each year
  • open enrollment, 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. 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 started Medicare parts A and/or B coverage
  • 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 the plan’s costs.

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