Dual-Eligible Special Needs Plans (D-SNP): a Primer

November 25, 2022

When President Lyndon B. Johnson signed the legislation that established Medicare and Medicaid as two distinct programs, he likely did not consider the challenges that would arise among those eligible for both – a group that happens to have a significant need for consistent and comprehensive medical, behavioral and community social services.

Congress’s attempt to bridge the gap in coordination of benefits, and reduce administrative / bureaucratic hurdles to receiving excellent care (i.e. which program is supposed to provide which benefits and when) came in 2003 with the creation of the Dual-Eligible Special Needs Plan (D-SNP) as part of the Medicare Prescription Drug, Improvement and Modernization Act. D-SNPs were authorized permanently in the 2018 Bipartisan Budget Act.

Essentially, D-SNPs contract with Florida’s Medicaid program to coordinate both Medicare and Medicaid benefits via a Medicare Advantage Plan. Every D-SNP must cover the same Medicare services that all Medicare Advantage plans are already required to provide - but will usually include supplemental services on top.

Some examples of additional assistance that may be included with D-SNPs, which we do not always see with traditional Medicare Advantage plans, include:

  • a monetary allowance for over-the-counter supplies and utility bills;
  • allowance for the purchase of healthy foods (with more comprehensive diet and nutrition advice);
  • allowance for fall prevention devices;
  • additional social worker and behavioral services support;
  • no referrals for providers/specialists in-network;
  • expanded dental benefits;
  • expanded hearing-aid and vision benefits (e.g. allowance for brand-name hearing aids and glasses);
  • expanded non-emergency transportation;
  • $0.00 copay on prescriptions.  

D-SNPs require the member to receive Part D benefits through their plan (they may not get a standalone Medicare prescription drug plan).

Becoming (or losing) dual eligibility will trigger a special enrollment period to choose a plan. Once enrolled, the D-SNP plan has 90 days to conduct a “Health Risk Assessment.” It identifies the member’s most urgent needs and creates an individualized care plan based on medical, functional, cognitive, psychosocial and mental health. All D-SNP members will have a PCP and care manager. But the care plan will incorporate an interdisciplinary team of specialists as needed.

After hospitalizations, members must receive a call within three days so the care manager can further explain and clarify the member’s diagnosis and care instructions. In addition, the care manager will help coordinate follow-up appointments (including scheduling transportation), needed home care, and durable medical equipment.

The National Center on Law and Elder Rights (NCLER) reports that several evaluations of the program have showed that dually-eligible Americans, who are enrolled in a D-SNP plan, have reduced hospitalizations, readmissions and nursing home admissions. However, NCLER admits that these evaluations are limited, and that more data is needed.

Practically speaking, our clients who are eligible for QMB (Qualified Medicare Beneficiary) ought to consider enrolling in a D-SNP plan so they can access expanded benefits.

Remember, those who do not immediately qualify for QMB (because they have too much by way of assets or income - or both) can engage a Florida elder-care lawyer for Medicaid Planning.

To speak to an insurance agent who focuses on senior-needs insurance solutions, including Dual-Enrolled Special Needs Plans (D-SNPs), please reach out to us today!