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Medicare: Qualifying for Dual Special Needs Plans

  August 07, 2019
By Vasilios “Voss” Speros, Arizona Medicare LLC

Over the years, the changes witnessed in Medicare provisions have been driven by population dynamics such as needs and market assessments. The Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage Special Needs Plan. Most of the plans under the platform are managed under the Health Maintenance Organization (HMO) plans and a few others under the Preferred Provider Organization (PPO) setups.

According to the initiators, the new Medicare Advantage (MA) plan was launched to cover persons suffering specifically identified diseases or characteristics. As of now, the D-SNPs only enroll persons with dual eligibility status. A study published by the Department of Health shows there are slightly more than 10 million people with dual eligibility. Most of these people need dedicated assistance on matters; physical health, behavioral health, and long-term support. Dual eligible represents about 20 percent of the entire Medicare population across the nation. However, statistics show a significant number of people with Medicaid and Medicare benefits are yet to enroll in a D-SNP.

The ambiguity in enrollment guidelines was largely because individuals approved for D-SNPs automatically fit into the Special Enrollment Period (SEP). Prospects can choose to enroll during the SEP or the appointed MA enrollment window. The beneficiaries must maintain their dual eligibility. Recently, CMS announced a few changes. At the start of January 2019, Dual SEP beneficiaries will be eligible to make a single change per quarter. The change should be made within the first 9 months of the year—January through September.

Before any individual is enrolled for D-SNP, their Medicaid eligibility must first be verified to streamline the care and service delivery. Most of this work is done by support personnel working under the various D-SNP carriers. The core Medicaid eligibility categories vary by what the respective states ascribe in their rules. The following categories are used in the approvals:
  • Qualified Medicare Beneficiary (QMB) Plus
  • Qualifying Individual (QI)
  • Qualified Medicare Beneficiary (QMB) Only
  • Qualified Disabled and Working Individual (QDWI)
  • Specified Low-Income Medicare Beneficiary (no other Medicaid) Only
  • Other Full Benefit Dual Eligible (FBDE)
  • Specified Low-Income Medicare Beneficiary (with other Medicaid) Plus
Types of Dual Special Needs Plans
The different categories of D-SNPs are arraigned based on type of beneficiaries enrolled in the programs. The model of care generally covers the unique need of the population; the target population and what the carriers are doing to serve the members. A CMS approved National Commission on Quality Assurance is tasked with the objective of evaluating the respective SNP models of care. According to CMS, the 4 types of D-SNPs are:

Dual Eligible Subset—for this category, admissibility is determined by the carrier with the help of a responsible state agency. The targets are segments of dual eligibles. The CMS is charged with making reviews and approvals for coverage based on the merits of each subset.

All-Dual—the admissibility for All-Dual is open to any dual-eligible beneficiary. These are Medicare Advantage qualified parties and those entitled to state approved Medicaid assistance. To enjoy optimal benefits, All D-SNPs must enroll all the segments of dual eligibles, including parties enjoying partial (limited cost sharing) and comprehensive Medicaid benefits.

Medicare Zero Cost Sharing—eligibility is open to dual eligibles with no commitments for cost sharing (Covering Parts A or B). It is important to reiterate that this D-SNP restricts enrollment to QMBs Only and the same category of QMBs who enjoy comprehensive Medicaid benefits. Because of the restrictions on QMB Only, an individual’s Medicaid cost sharing may be requested.

Full Benefit—eligibility is open to dual eligibles with access to full Medicaid benefits for the stipulated month and covers all the eligible categories approved under the Medicaid State Plan. Under this arrangement, a D-SNP is also mandated to enroll all parties eligible for Medical assistance under the stipulated sections of the law.

Benefits offered under the Dual Special Needs Plans
Arizona and other states in the US have the mandate to approve the D-SNPs and the benefits offered by carriers working in their jurisdictions. Statistics also show there are about 1.1 million in Arizona getting Medicare benefits. The more conjoint benefits under the D-SNP include:
  • Zero monthly premiums
  • Care co-ordination
  • Telehealth services
  • Transportation perks
  • Part D particulars
  • Dental, hearing, and vision benefits
  • Gym memberships
  • Over the Counter (OTC ) items quarterly benefits (from places like CVS and Walgreens)
A string of rules has been put in place to define who qualifies for D-SNP Plans. For Medicare, one of the qualifications is attaining age 65 or having a qualified disability. The eligibility for Medicaid is mostly tied to the individual’s income status and asset threshold. The threshold is capped by the respective states. The agency tasked with this mandate in Arizona is an administration called the Arizona Health Care Cost Containment System (AHCCCS).

Most D-SNP prospects living in Arizona are in and around urban areas and places with low income populations. The D-SNP model may not be fully realized or utilized in rural areas or states with no active Medicaid managed care due to several reasons. The most poignant is low coverage and enrollment to sustain the program as dictated by state and federal laws.

Have questions? If you want to know more about D-SNP, Arizona Medicare or Medicaid, allow me to help you with information and resources; contact Voss at Arizona Medicare 480-999-4409. Back to Top

August 07, 2019


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