Many individuals on Medicare find themselves struggling to pay premiums and copays. If your income falls below a certain threshold, you may be eligible for Medicaid in addition to Medicare. These types of plans are known as DSNPs or Dual Eligibility Special Needs Plans.
What are Dual Eligibility Plans? (DSNP)
DNSP’s are a type of Medicare Advantage Plan. They encapsulate the benefits of Medicare Part A, Part B, and Part D. With a DSNP, most of your hospital, outpatient, and prescription drug needs will be covered. There is a tremendous amount of overlap in benefits provided by Medicare and Medicaid. If you are dually eligible, you retain all of the benefits of both programs. You can peruse these helpful articles to learn all about both programs (Medicaid & Medicare).
What Benefits do DSNP’s Offer?
Dual Eligibility plans offer the full benefits of Medicaid, plus Medicare Advantage, and a few more thrown in for good measure!
Medicaid is a program jointly funded by the federal government and individual states. States have a certain control over the type, amount and duration of services offered. However, they must meet Federal guidelines. This means that there are certain mandatory benefits that must be offered. But, states can choose to offer additional benefits.
Medicare Advantage replaces Original Medicare (Medicare Parts A & B) and incorporates Medicare Part D (prescription drug coverage). If you have dual eligibility, you will have benefits such as:
- Inpatient procedures
- Outpatient procedures
- Nursing care both in facilities and at home
- Hospice
- Preventative services
- Mental health services
- Medical equipment
- Prescription drug coverage
- Dental
- Vision
- Hearing
- And more!
The list is truly quite extensive. Additionally, DSNPs offer extra benefits such as:
- Transportation to and from appointments
- Richer and more extensive dental benefits
- Some carriers even offer meals after procedures
With a Dual Eligibility Special Needs Plan, you are guaranteed comprehensive coverage. However, the benefits can vary quite a bit because DSNPs are offered by private carriers. These private carriers offer different benefits to compete for your business. For this reason, we recommend working with a broker who can find the best plan for you.
Am I Eligible?
In order to be considered dually eligible, you must be eligible for Medicaid and Medicare.
Medicaid Eligibility:
Eligibility for Medicaid is determined by a series of factors: largely income, household size, and your state’s individual regulations. You are most likely eligible for some type of Medicaid program if:
You make less than 100%-200% of the federal poverty level
AND
Are pregnant, elderly, disabled, or a parent/caretaker of a child?
***If you make less than 133% of the FPL, there is likely a program available for you, but it really depends on your state.
Additionally, to be eligible for Medicaid, you must meet certain non-financial criteria. Generally speaking, Medicaid beneficiaries must be residents of the state in which they are receiving Medicaid. They must be either citizen of the United States or legal permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy, or parenting status.
Also, states have the option to establish a “medically needy program”. This helps individuals who would be disqualified for Medicaid based on their income BUT who have significant health needs. Medically needy individuals can still become eligible by “spending down”. Individuals spend down by incurring expenses for medical care for which they do not have health insurance. If your medical expenses are large enough, it may push your income down enough to make you eligible for Medicaid. Luckily, most states have adopted a medically needy program.
Eligibility can be a tricky topic and it really does vary from state to state. For this reason, you are going to want to contact your state’s Medicaid office or log on to medicaid.gov for additional resources.
Medicare Eligibility:
Additionally, in order to enroll in a Dual Eligibility Special Needs Plan, you must be eligible for Medicare. You are eligible for Medicare benefits if:
- You are over 65 and a U.S. citizen or you are over 65 and a permanent legal resident who has lived in the United States for at least five years
- You are receiving social security or railroad retirement benefits OR have worked long enough (40 quarters) to be eligible for benefits even if you are not collecting them yet
- You are also eligible if you are over 65 and you or your spouse is a government employee or retiree who has not paid into social security, but who has paid into Medicare payroll taxes while working, meaning a Medicare-covered job.
If you are under 65, you are eligible for Medicare Parts A & B benefits if:
- You have received social security benefits for at least 24 months. These months do not have to be consecutive
- You have ALS
- You have the end-stage renal disease (as of 2021)
How Do I Enroll?
You will need to provide documentation to enroll in a DSNP. First, you must be able to present your Medicaid card. To enroll in Medicaid, contact your state’s Medicaid office or log on to medicaid.gov for additional resources.
You can enroll in a dual eligibility plan during your individual open enrollment or during the annual open enrollment. Your individual open enrollment is the three months before your turn 65, your birth month, and the three months after. The annual enrollment period is the same time every year from October 15-Dec. 7. During this time you may join, switch or drop a plan.
DSNP’s are a type of Medicare Advantage plan. So the hospitals and doctors you wish to visit must be in network, i.e. they must accept your carrier’s plan. You can check with your doctor in advance to determine which plans they accept. Most DSNP’s operate as HMO’s (although there are some PPO options). Traditionally, HMO’s require a primary care physician. Check out all of the options available to you on Medicare.gov by accessing the plan finder.
You may also contact your carrier of choice and work with an agent during your individual open enrollment period or during the annual enrollment period. You’ll need to provide your Medicaid card and possibly additional information. Finally, you can work with a broker who will help you compare and contrast all the plans available to you.
How Much Do Dual Eligibility Plans Cost?
Your costs for a Special Needs Plan vary dependent upon your level of need and your state. Although these plans are regulated by Medicare the premiums and copays are determined by the carrier. You may still have to pay for Medicare Part B plus an additional monthly premium or not at all. The prices and benefits may vary. However, if DSNP is available to you, it’s definitely an option that you will want to pursue. You will have access to more benefits than just Medicare and Medicaid. Usually, there are cost-saving benefits as well.
Working with a broker will ensure you enroll in the best possible plan, at the lowest possible rate. You can reach one of our licensed brokers at iHealthBrokers at (888) 918-0518 or schedule an appointment today!
Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.
