Dual Eligible Special Needs Plans (D-SNPs) are limited to people who qualify for Medicare and Medicaid .
You may be eligible for a D-SNP even if you’re younger than 65.
Since Medicaid eligibility requirements vary by state, you may not be eligible where you live, even if you are low-income or have a specific disability.
You can usually own a home and/or a car and still be eligible for a D-SNP.
A Dual Special Needs Plan (D-SNP) is a type of Medicare Advantage (Part C) plan. D-SNPs are for people who are eligible for both Medicare and Medicaid. You must already be enrolled in both programs to qualify for a D-SNP.
D-SNPs are offered by private insurers who are approved to sell Medicare plans. They’re not offered in every state, and the coverage they provide may vary from plan to plan.
D-SNPs always cover at least as much as Original Medicare (Part A and Part B) does. They also provide Part D (prescription drug) coverage.
In addition, D-SNPs offer benefits that Medicare doesn’t pay for. These include personal care services and nursing home care.
D-SNPs eliminate many out-of-pocket costs, such as coinsurance, deductibles, and copays. This means you won’t have to postpone hospitalizations or preventive care appointments due to lack of funds.
Many D-SNPs also provide full or partial coverage for extras you may benefit from, such as:
- Dental care
- Vision care
- Hearing aids and fittings
- Gym memberships (Silver Sneakers)
- Over-the-counter medications, supplements, and products
- Non-emergency transportation
- Home meal delivery
- Home support services
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To qualify for a D-SNP you must be eligible for Medicare and for Medicaid in your state of residence:
Am I Eligible for Medicare?
Medicare is a federal program. Eligibility requirements for Medicare don’t vary from state to state. To be eligible for Medicare, you must be a U.S. citizen, or qualifying non-citizen. You must also be in one of the following categories:
- You’re 65 or older.
- You’re under 65 and have received Social Security disability benefits or certain Railroad Retirement disability benefits for 24 months or more.
- You’re any age and have end-stage renal disease.
- You’re any age and have amyotrophic lateral sclerosis (ALS).
Am I Eligible for Medicaid?
Medicaid is a joint federal and state program. Each state has differing eligibility requirements. No matter what state you live in, you must be a U.S. citizen or qualifying non-citizen to apply.
There are seven eligibility categories for Medicaid:
- Full Medicaid
- Qualified Medicare Beneficiary without other Medicaid (QMB Only)
- QMB Plus
- Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB Only)
- SLMB Plus
- Qualifying Individual (QI)
- Qualified Disabled and Working Individual (QDWI)
Your state of residence will determine the income and resources criteria you must meet to be eligible in any category. The benefits and qualifications for each category vary.
In general, eligibility for Medicaid is limited to people who have a low income and/or specific disabilities, such as blindness.
Some states also have medically needy programs. These programs expand eligibility to people with significant health expenses, who make a too-high salary. Medically needy programs let you “spend down” your assets by deducting your medical expenses from your income until it meets the Medicaid-approved level.
In some states you will be required to have limited financial resources, apart from your income. Resources refer to bank accounts, stocks, bonds, and other monetary assets. Most states allow single applicants to retain $2,000 or more in resources. Pre-paid funeral and burial plans are exempt.
Home ownership does not exempt you from Medicaid in most instances. Based upon your state of residence, your home’s equity value may need to be below a certain dollar amount for you to be eligible.
Car ownership doesn’t typically exempt you from Medicaid.
Do I Meet the Plan’s Criteria for Eligibility?
You must also meet certain requirements to be eligible for the specific D-SNP you choose. These include:
- Being able to provide documentation and proof of your Medicare and Medicaid coverage.
- Residing in a county where the plan is offered.
HMO D-SNPs are a type of Medicare Advantage plan. It is up to the insurer as to which type of D-SNPs they will offer in any given county or state. These include HMO D-SNPs.
HMO stands for Health Maintenance Organization. Like any HMO, an HMO D-SNP only pays for medical services provided by suppliers in their network.
HMO networks contain:
- Doctors, including primary care physicians (PCPs) and specialists
- Suppliers of durable medical equipment
- And more
Some HMO D-SNPs may require that you see your PCP before you see a specialist.
If you choose to see a doctor outside of the plan, your HMO D-SNP may not reimburse you for services, or, they may reimburse you a smaller amount than they would if you saw an in-network provider.
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