Dual Special Needs Plans (DSNPs) are a type of Medicare Advantage health plan designed for consumers with both Medicare and Medicaid and categorized as a Full Dual Eligible under the Medicare Savings Program. These individuals receive Medical benefits through Medicaid and additionally receive assistance in paying Medicare premiums, deductibles, and coinsurance. 12.9 million people received health coverage under both Medicare and Medicaid in 2021, and according to KFF.org, in 2023, 5.2 million dual-eligible individuals were enrolled in a Medicare Advantage plan designed specifically for dual-eligible individuals. DSNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes. DSNPs typically provide benefits not otherwise available in traditional Medicare and generally do not charge a premium.
Who is a candidate for a DSNP?
Consumers who have both Medicare and Medicaid and who are categorized as Full Dual Eligible under the
Medicare Savings Program. These individuals receive Medical benefits through Medicaid and additionally
receive assistance in paying Medicare premiums, deductibles and coinsurances.
The Full Dual Eligible categories include:
- FBDE: Full Benefit Dual Eligible – these individuals only have Medicaid benefits and will be responsible
for the cost sharing for Part A & B services (deductibles, copays, and coinsurance) - QMB+: Qualified Medicare Beneficiary Plus Full Medicaid benefits
- SLMB+: Specified Low-Income Medicare Beneficiary Plus Full Medicaid benefit
The Partial Dual Eligible categories include:
- SLMB: Specified Low-Income Medicare Beneficiary
- QDWI: Qualified Disabled and Working Individual
- QI: Qualifying Individual
What are the eligibility requirements to enroll in a DSNP?
To be eligible for a DSNP the consumer must be:
- Entitled to Medicare Part A
- Enrolled in Medicare Part B
- United States citizen or lawfully present in the United States
- Receive state Medicaid benefits also known as Medicare Savings Program (qualifying Medicaid
category) - Reside in the plan’s Service Area
What are different dual eligibility levels/categories?
Medicare consumers may get help from their state to pay for their Medicare premiums. These programs are
also known as Medicare Savings Programs. In some cases, the Medicare Savings Programs may also pay for
Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and
copayments if they meet certain conditions set by the state. Below are the lists of Medicare Savings Programs
that may be available in a state. Note: Medicaid eligibility levels and qualifying requirements varies by state.
How do I know if a person has full dual eligibility?
To determine what level of benefit the consumer has (Medicare Savings Program) you can review the
consumer’s state “Award Letter,” contact the state Medicaid office, or look at the consumer’s Medicaid card.
What are common SEPs for dual-eligible consumers?
SEP-DUAL/LIS (MAINTAINING SEP) Dual eligible or Low Income Subsidy (LIS) eligible consumers
who are maintaining their status have a quarterly (not monthly) opportunity to change plans within the
first nine months of the calendar year.
SEP-DUAL/LIS (CHANGE IN STATUS) Dual eligible or LIS eligible consumers who had a change in
either their Medicaid Assistance (Medicare Savings Program) or LIS/Extra Help level or lost the
assistance, will have the opportunity to change plans within 3 months of their notification of change or
from when the change went into effect, whichever is later.
How does a consumer know if there has been a change in their level of assistance?
A consumer will receive a “Notification Letter” from CMS or their state when their LIS or Medicare Savings
Program level changes. The letter indicates the effective date of the change.
What happens if a DSNP member loses their Medicaid eligibility for the plan?
f a D-SNP member loses Medicaid eligibility for the plan, the member can remain enrolled in the DSNP for a
period of continued eligibility, which is often called the “grace period.” The grace period can vary in length from
1 to 6 months but is generally 6 months for most DSNPs. Additionally, a Special Election Period (SEP) (DUAL LIS (change in status) is available for DSNP members who lose Medicaid eligibility. This SEP begins the month the member is notified by the plan of the loss of Medicaid eligibility and ends when they enroll into a different Medicare Advantage Part D plan or 3 months after they have been disenrolled from the DSNP, whichever is earlier. Note: DSNP members in a grace period due to the loss of Medicaid eligibility (e.g., Medicare Savings
Programs) are responsible for paying their Medicare Part A and B cost sharing.
How can a Medicaid-eligible consumer recertify for Medicaid?
Medicaid recipients can recertify as early as 90 days from termination – which is generally preferred, but in
most states, the opportunity is allowed 60 and 30 days from termination as well. If the Medicaid recipient DOES NOT recertify in time, depending on the state, there may be a lapse of time, up to 90 days from the date of termination, to comply. This does not necessarily mean they will be reinstated if they comply. They must still meet all conditions of eligibility.
How do I get started helping dual eligibles?
Check with your Agent Pipeline consultant to ensure you're appointed, certified, and ready to sell with insurance companies offering DSNP plans in your service areas. You can also leverage our Medicaid Resource Center on the MARC for additional resources, including contacts to your state Medicaid offices and community organizations who may be able to assist your Medicaid-eligible clients further.
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