The Truth About (D-SNP) Medicare Special Needs Plans

Some of the most advanced and innovative Medicare Special Needs Plans are those that offer D-SNP or Drug Subsidy. This is a plan that will not only cover your drug costs, but also offers protection against high out-of-pocket expenses incurred by co-payments, coinsurance, and deductibles.

These plans can be very beneficial for senior consumers who have chronic conditions such as diabetes, arthritis, or heart disease requiring them to take expensive medications on a daily basis.

The truth about these plans? They are available without regard for age or income level and they provide coverage for drugs even if you cannot get them through your prescription drug plan.

Medicare special needs plans are Medicare advantage plans made for those with special needs. There are plans for chronic health conditions, institutionalized beneficiaries, and those on both Medicare and Medicaid.

There are a lot of things to consider before enrolling in these plans. Medicare special needs plan eligibility guidelines help keep people off these plans who wouldn’t benefit from them.

But just because you are eligible, doesn’t mean these are the right plans for you.

Medicare advantage dual-eligible special needs plans (D-SNP)’s are for beneficiaries on Medicare and Medicaid. Medicare dual special needs plans provide extra help for low-income individuals. Here we’ll see how these plans work, and whether or not they are right for you.

DUAL ELIGIBLE (D-SNP) PLANS FOR THOSE ON MEDICARE AND ELIGIBLE FOR MEDICAID

Medicare and Medicaid are healthcare programs with different healthcare benefits. Medicare gets funding from the taxes you pay, and the Part B premium you pay after age 65. Medicaid gets funding from the state and is in place for adults of any age who need financial help.

Both programs help you pay for your healthcare expenses, and you could be eligible for both. In such circumstances, the government refers to them as DUALLY ELIGIBLE.

Receiving both Medicare and Medicaid helps lower healthcare costs for those who have limited resources. Getting dual coverage follows a general rule; Medicare pays their parts, and Medicaid picks up the rest.

Coverage for dual-eligible beneficiaries often varies by region. While some regions offer Medicaid through Medicaid-managed care plans, others provide Fee-for-Service Medicaid coverage. Some regions contact with health plans that provide both Medicare and Medicaid benefits.

The journal of Health affairs estimates that, out of all dual-eligible beneficiaries, an estimated two-thirds meet the requirements for Medicare based on age while the remaining one-third meet the requirements on the basis of their disabilities.

Over 12 million Americans make up the Dual Eligible population which is about 20% of the Medicare Population, according to www.psmbrokerage.com. Less than 30% of Dual eligibles are enrolled in a Medicare Advantage plan or Special Needs Plan (D-SNP)

DUAL SPECIAL NEEDS PLAN (D-SNP)

Dual Eligible Special Needs plan or D-SNP is a special kind of Medicare Advantage plan that provides health benefits for individuals who are dual-eligible, that is, they qualify for both Medicare and Medicaid.

It is an all-in-one plan that combines your Medicare Part A and Part B benefits, your Medicare Part D prescription drug coverage, your Medicaid benefits, and additional benefits such as vision, dental, or fitness.

States cover some Medicare costs, depending on the state and the eligibility of the individual involved. Your state also decides which D-SNPs can be offered to you. Generally, a Dual Special Needs plan (D-SNPs) would include the following:

• $0 Monthly premiums
• Care coordination via a personal care coordinator
• Vision and hearing benefits
• Over the counter quarterly benefits
• Transportation benefits
• Telehealth services 
• Gym membership
• Part D coverage.

In addition, the D-SNP plan includes coverage for Medicare Part A (Hospital services), Medicare Part B (Medical health care needs), and Medicare Part D (Prescription drug coverage), and extra benefits not provided by either Medicare or Medicaid, all through a single health plan.

With a DSNP plan, there are certain social services available to help coordinate a beneficiary’s Medicare and Medicaid benefits.

WHO IS ELIGIBLE FOR A DUAL SPECIAL NEEDS PLAN (D-SNP)?

If you are qualified for both Medicare (Federal government-run program) and Medicaid (State government-run service); and have a specific disabling or severe chronic condition, then you are eligible for D-SNP.

To qualify for Medicare, an intending enrollee must be 65 years or older or have a qualifying disability. On the other hand, to qualify for Medicaid income and asset level of intending you must fall below a certain threshold as determined by your state.

The Dual Special Needs Plan (DSNP) is there to address the health needs of those who fall in the above categories. 

DSNP beneficiaries often face special health needs and could use such coordinated assistance to improve their health and quality of life. For example, they may be experiencing the following:

• A disabling condition and difficulty with routine activities such as bathing and dressing
• A mental disorder or cognitive impairment
• Have a variety of health conditions and require care from multiple doctors to manage their health
• Incapacitated by an underlying health condition and require the services of in-home care providers and other health and social services.

HOW DO I ENROLL FOR A D-SNP?

If you are eligible for the Dual Special Needs Plan (check if you qualify through the Medicaid office in your state or by using this online tool).

D-SNP eligible can enroll during the regular Medicare advantage enrollment period or Special Enrollment Period (SEP). The Special Enrollment Period is for (D-SNP)’s is once every quarter.

If you meet Medicare special needs plans eligibility, or you recently lost eligibility, you can make a change every three months. A person can enroll in D-SNPs during the following Medicare enrollment periods:

• January 1^st to March 31^st 
• During Open Enrollment Period (OEP) from October 15^th to December 7^th 
• In the Special Enrollment Period (SEP) if there is a change in a person’s circumstances, such as relocating to a new area.

For those who, for some reason, lose their Medicaid eligibility, they have a Special Enrollment Period starting at that particular month they receive the notice of the loss of eligibility plus two additional months to make an enrollment choice.

Note that, a beneficiary can only remain enrolled in a Special Needs Plan as they meet the eligibility requirement of the plan. If their health situation improves and they no longer meet the enrollment requirements for the Special Needs plan, they will get a Special Election Period to switch to a different Medicare Advantage plan or return to Original Medicare.

TRANSPORTATION BENEFITS FOR DUAL ENROLLEES

Older adults require transport benefits given their frailness due to vision or cognitive decline as well as physical changes which impair their ability to drive or make use of public transport services.

Over 50% of non-drivers 65 years or older stay at home and this dynamic may cause social isolation and prevent access to needed long-term services and supports that keep older adults in the community. 

Though non-emergency transportation services are not included in the list of mandatory Medicare and Medicaid benefits enshrined in statute, there are required by federal regulation nonetheless.

These regulations require state Medicaid plans to ensure necessary transportation for recipients to and from providers. However, Medicare Advantage plan (Medicare Part C) May offer additional services or expanded coverage.

Dual eligibles enrolled in a Medicare advantage plan should inquire with their plan about non-emergency medical transportation options offered by the plan to in-network providers by reviewing member handbook or member services.

Since Medicaid is a payer of last resort, dual-eligible may be expected to exhaust any transportation services available to them, if any, under their Medicare Advantage plan before Medicaid will reimburse for non-emergency transportation.

In a similar vein, dual eligibles who enroll in D-SNPs may find that their plan offers supplemental transportation to medical services.

As an increasing number of states adopt managed care delivery systems for Medicaid, older adults may find that their non-emergency medical transportation is provided through their Medicaid-managed care plan.

OVER-THE-COUNTER (OTC) BENEFITS FOR DUAL ENROLLEES

There are Over-the-Counter benefits available for dual enrollees. If you have Medicare and Medicaid and live in a coverage area, you may qualify for OTC benefits.

After successfully enrolling, your plan provider will give you money (if the plan is available to you) to purchase personal care and wellness products like vitamins, bandages, and toothpaste without getting to leave your home.

This is one of the money-saving benefits of Medicare Advantage plans, though the benefits vary by plan. If your plan has the benefit, you get a specified dollar amount to spend for a $0 copay. Beneficiaries are able to get all the drugstore items they need at little or no cost at all.

Items covered under OTC benefits include; generic and brand name products for allergy, sinus, cold, and flu; pain relief; home health care and daily living; supports; braces and wraps; dental and oral health; eye and ear care; first aid; smoking cessation; diabetes care; foot care; digestive health; incontinence; skincare; sleep aids and vitamins. Prices for these items may vary depending on your plan.

HEALTHY FOOD ALLOWANCE FOR DUAL ENROLLEES

With the healthy food allowance, dual enrollees can get healthy food at no cost. The healthy food allowance is developed to assist dual enrollees on a limited budget who can seldom afford healthy food. It is one of the many dual benefits you could get with a dual healthy plan and it is meant to assist dual enrollees to stretch their monthly food budget.

Some dual health plans give enrollees a monthly cash token of up $60 on the first day of every month. Eligible enrollees get a set amount of credit loaded onto a prepaid debit card. This money serves as free food credit, so members can use that to shop for groceries, then pay with their debit card.

Any unused amount will automatically be rolled over to the first day of the next quarter, while the entire remaining amount expires on the last day of the year. 

This allowance doesn’t cover nonfood items such as; alcohol, baby formula, candy, chips, coffee shop items, desserts, fresh baked goods, soda, and tobacco.

Technically, these are your favorite groceries but they do not qualify as healthy foods. What the healthy food allowance covers include; fruits and vegetables, meats and seafood, dairy products, soups, healthy grains, beans and legumes, water and mineral water, pantry staples, and more.

Conclusion

Medicare Special Needs Plans are a great way to get additional coverage and benefits that you may not be able to receive with Original Medicare alone.

Though these plans have some downsides, they can also provide coverage for expenses like long-term care insurance or prescription drugs which could save the plan holder thousands of dollars in medical costs during retirement years.

To find out if this type of supplemental plan is right for you, please call us at 1-855-380-3300. Our specialists will help guide you through your options so that we can find the best fit for both your needs and budget. Don’t wait! Call now before it’s too late!