Many brokers tend to shy away from selling dual-special needs plans (D-SNPs) due to the perceived complexities associated with these plans. However, once you understand the basics, you will be well-positioned to introduce the topic and advise your clients.
By taking the initiative to educate your clients about D-SNPs, you can demystify the perceived complexities and highlight the benefits they offer. Start by explaining the fundamental concept of D-SNPs: These plans are specifically designed to cater to individuals who qualify for both Medicare and Medicaid. They provide comprehensive coverage that combines the benefits of both programs, offering a holistic approach to healthcare for eligible individuals.
To further ease any concerns your clients may have, you can break down the workings of D-SNPs into simpler terms. Emphasize that D-SNPs operate like other Medicare Advantage plans, providing coverage for medical services, prescription drugs, and additional benefits such as
dental and vision care. However, unlike traditional Medicare Advantage plans, D-SNPs are uniquely tailored to meet the specific needs of individuals who are dually eligible for Medicare and Medicaid.
What does it mean to be dually eligible?
Dual eligibility is a fancy term for saying an individual can have Medicare and Medicaid at the same time. D-SNPs are a type of Medicare Advantage plan (also known as Part C) that offers broader coverage to a specific population. These private plans help coordinate care between Medicare, a federal program, and Medicaid, controlled by the states. Nearly 12 million Americans are enrolled in both Medicare and Medicaid according to the Kaiser Family Foundation.
To be considered for a D-SNP individuals must first be enrolled in Medicare Part A, which covers hospitalizations, and/or Medicare Part B, which covers other medical services. Individuals are also enrolled in either full-benefit Medicaid or the Medicare Savings Program. These programs, controlled by each state, help beneficiaries with some, or all, of their Medicare Parts A and B expenses. These individuals are “dually eligible,” meaning they receive their primary health insurance coverage through Medicare benefits and get some assistance from their state Medicaid programs.
Dual eligible programs are typically offered to people with low income, who have specific medical conditions or have unique health care requirements.
What plan is your client eligible for?
As a broker, your clients are looking to you to help them understand their options, particularly if they are eligible for D-SNPs. There are five categories of D-SNPs. Which plan a client can enroll in depends on the Medicaid category they fall under.
- All-Dual Dual Special Needs: Any dual eligible beneficiary.
- Full-Benefit Dual Special Needs: Dual-eligible individuals who qualify for full Medicaid benefits for the month under any eligibility category, or medical assistance for any month if the individual was eligible for assistance in any part of the month.
- Medicare Zero Cost Sharing: Dual-eligibles who are not responsible for cost sharing for Medicare Parts A or B. Cost sharing is the “out-of-pocket” payments individuals make for medical services that insurance does not cover, such as deductibles, copayments and coinsurances.
- Dual Eligible Subset: This subset is determined by a Medicare Advantage organization in coordination with the state Medicaid agency. The Centers for Medicare and Medicaid Services reviews and approves requests for coverage of dual eligible subsets on a case-by-case basis. For states that use these plans, the D-SNP is charged first for medical services, then Medicaid picks up the cost share, covering some out-of-pocket costs and benefits.
- Dual Eligible Subset Medicare Zero Cost Sharing: Similar to the plan above, but does not include cost sharing.
Navigating the complexities of D-SNPs requires a comprehensive understanding of the program’s nuances, eligibility criteria and benefits. If you are unsure about the important details of D-SNPs, it is crucial to work with a trusted agency partner that can provide you with additional guidance and support. Collaborating with an experienced general agency allows you to provide your clients with accurate and up-to-date information and ensures you can offer your clients the best possible solutions tailored to their specific requirements.
What is Medicaid Redetermination?
Medicaid enrollment has skyrocketed since the start of the pandemic, likely due to the continuous enrollment provision. The provision was part of the COVID-19 Public Health Emergency (PHE) and prevented states from disenrolling people from Medicaid during the pandemic. In return, the states received enhanced federal funding.
Since the PHE ended in May 2023, many states have begun Medicaid redetermination, meaning they are looking over subscribers to determine if they are no longer eligible for benefits. Over the next 12 to 14 months, up to 24 million individuals that no longer meet state Medicaid criteria will be removed. As states review their Medicaid eligibility criteria, you may come across a situation where D-SNPs serve as an excellent solution to assist your clients affected by the Medicaid evaluation process. This presents a valuable opportunity to advise clients to discuss Medicaid redetermination with their employees. It is important to prioritize the well-being of employees who no longer qualify for Medicaid because they now meet the requirements for employer-sponsored healthcare. To ensure their best interest, it is strongly recommended to assist them in signing up for a plan during the open enrollment period.
