Dual Eligible Special Need Plans (D-SNP)
Dual Eligible Special Needs Plans (D-SNPs) enroll beneficiaries who are entitled to both Medicare (Title XVIII) and Medical Assistance from a State Plan under Title XIX (Medicaid), and offer the opportunity of enhanced benefits by combining those available through Medicare and Medicaid.
Please visit the following sections for more information on D-SNPS.
- Medicaid Eligibility Categories
- Types of D-SNPs
- Fully Integrated Dul Eligible SNPs
- Benefit Flexibility for Certain D-SNPs
- D-SNP Marketing
In addition, please visit the Medicare Managed Care Manual (MMCM), chapter 16b, the Special Needs Plan FAQ and the State Resource Center FAQ; these resources may be accessed in the Download Section below. For more information on the D-SNP State Contracting process, please visit the State Resource Center which you can access from the left menu on this page.
D-SNPs are open to beneficiaries in all Medicaid eligibility categories, including:
|Qualified Medicare Beneficiary without other Medicaid (QMB only)||An individual entitled to Medicare Part A, with an income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for Supplementary Social Security Income (SSI) eligibility, and who is not otherwise eligible for full Medicaid benefits through the State. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance for Medicare services provided by Medicare providers to the extent consistent with the Medicaid State Plan.|
|QMB+||An individual who meets the standards for QMB eligibility, and who also meets the criteria for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, Medicare deductibles and coinsurance, and provides full Medicaid benefits to the extent consistent with the State Plan. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or by spending down excess income to the Medically needy level.|
|Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB only)||An individual entitled to Medicare Part A, with an income that exceeds 100% FPL but less than 120% FPL, with resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid. These individuals are eligible for Medicaid payment of the Medicare Part B premium only. They do not qualify for any additional Medicaid benefits.|
|SLMB+||An individual who meets the standards for SLMB eligibility, and who also meets the criteria for full State Medicaid benefits. These individuals are entitled to payment of the Medicare Part B premium, in addition to full State Medicaid benefits. These individuals often qualify for Medicaid by meeting Medically Needy standards or by spending down excess income to the Medically Needy level.|
|Qualifying Individual (QI)||An individual entitled to Medicare Part A, with an income at least 120% FPL but less than 135% FPL, and resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid benefits. This individual is eligible for Medicaid payment of the Medicare Part B premium.|
|Qualifying Disabled and Working Individual (QDWI)||An individual who has lost Medicare Part A benefits due to a return to work, but is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. These individuals are eligible for Medicaid payment of the Part A premium only.|
|Other full benefit dual eligible (FBDE)||An individual who does not meet the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home and community-based waivers.|
Although D-SNPs are available to beneficiaries in all Medicaid eligibility categories, D-SNPs may further restrict enrollment to beneficiaries in certain Medicaid eligibility categories. CMS divides D-SNPs into the following four categories, according to the types of beneficiaries that the SNP enrolls:
|All-Dual D-SNPs||An all-dual D-SNP enrolls beneficiaries who are eligible for Medicare Advantage and who are entitled to Medicaid assistance under a State/Territorial plan. An all-dual D-SNP must enroll all categories of dual eligible individuals, including those with comprehensive Medicaid benefits as well as those with more limited cost sharing.|
|Full-Benefit D-SNPs||A full-benefit D-SNP enrolls individuals who are eligible for:
|Medicare Zero Cost Sharing D-SNPs||This type of D-SNP limits enrollment to QMBs only and QMBs with comprehensive Medicaid benefits (QMB+), the two categories of dual eligible beneficiaries who are not financially responsible for cost sharing for Medicare Parts A or B. Because QMB-only individuals are not entitled to full Medicaid benefits, there may be Medicaid cost sharing required.|
|Dual Eligible Subset D-SNPs||MA organizations that offer D-SNPs may exclude specific groups of dual eligibles based on the MA organization’s coordination efforts with State Medicaid agencies. CMS reviews and approves requests for coverage of dual eligible subsets on a case-by-case basis. To the extent that a SMA excludes specific groups of dual eligibles from their Medicaid contracts or agreements; those same groups may also be excluded from enrollment in the SNP, as long as the enrollment limitations parallel the structure and care delivery patterns of the State Medicaid program. Dual Eligible Subset D-SNPs can be a Dual Eligible Subset that includes cost sharing (Dual Eligible Subset) or does not include cost sharing (Dual Eligible Subset Medicare Zero Cost Sharing).|
For more information on the types of D-SNPs, please visit the MMCM, chap. 16b, section 20.2, which can be accessed in the Download Section below.
Fully Integrated Dual Eligible (FIDE) SNPs were created by Congress in section 3205 of the Affordable Care Act (ACA). Designed to promote the full integration and coordination of Medicare and Medicare benefits for dual eligible beneficiaries by a single managed care organization, FIDE-SNPs are described in section 1853(a)(1)(B)(iv) of the Social Security Act and at 42 CFR §422.2. FIDE SNPs must meet the following five elements:
- Enroll special needs individuals entitled to medical assistance under a Medicaid State Plan, as defined in Section 1859(b)(6)(B)(ii) of the Act and 42 CFR Section 422.2 and described in detail in Section 40.5.3 of this chapter;
- Provide dually-eligible beneficiaries access to Medicare and Medicaid benefits under a single managed care organization;
- Have a CMS approved MIPPA compliant contract with a State Medicaid Agency that includes coverage of specified primary, acute, and long-term care benefits and services, consistent with State policy, under risk-based financing;
- Coordinate the delivery of covered Medicare and Medicaid health and long-term care services, using aligned care management and specialty care network methods for high-risk beneficiaries; and,
- Employ policies and procedures approved by CMS and the State to coordinate or integrate enrollment, member materials, communications, grievance and appeals, and quality improvement.
For more information on FIDE SNPs, please visit the MMCM, chap. 16b, section 40.4.3, which can be accessed in the Download Section below.
Regulations at 42 CFR Section 422.102(e) allow D-SNPs that meet a high standard of integration and minimum performance and quality-based standards to offer supplemental benefits beyond those currently permitted for MA plans. In order to meet the minimum contract requirements for the purposes of qualifying for the benefits flexibility, the D-SNP must:
- Be a specialized MA plan for dually-eligible special needs individuals described in Section 1859(b)(6)(B)(ii) of the Act;
- Be operational in the upcoming contract year,
- Have operated the entire previous calendar year;
- Facilitate access to all covered Medicare benefits and all Medicaid benefits covered in the State Medicaid plan;
- Have a current capitated contract with a State Medicaid Agency that includes coverage of specified primary, acute, and long term care benefits and services to the extent capitated coverage is consistent with State policy;
- Coordinate delivery of covered Medicare and Medicaid primary, acute, and long term care services throughout its entire service area; and,
- Possess a valid contract arrangement with the State, in accordance with CMS policy and the requirements at 42 CFR Section 422.107.
In order to meet the qualifying standards for benefits flexibility eligibility, the D-SNP must also:
- Have received a 3-year approval of its model of care most recently reviewed by the National Committee for Quality Assurance (NCQA); and,
- Either be in a contract with a current 3 star (or higher) overall rating on the Medicare Plan Finder website; or, if the D-SNP is part of a contract that does not have sufficient enrollment to generate a star rating, the ratings will be based upon the most recent SNP plan-level HEDIS measures.
CMS does not intend for the additional Medicare supplemental benefits that are offered under this flexibility to replace State Medicaid or local benefits for enrollees that are eligible to receive identical Medicaid services. Rather, D-SNPs are expected to use the flexibility to design their benefits in a way that adds value for the beneficiary by bridging the gap between Medicare and Medicaid covered services.
For more information on the Benefit Flexibility for certain D-SNPs, please visit the MMCM, chap. 16b, sections 40.4.4 and 40.4.5, which can be accessed in the Download Section below.
In addition to the general marketing guidelines that all MA organizations must follow, D-SNPs are required to send the standardized, combined Annual Notice of Change (ANOC)/Evidence of Coverage (EOC) to all current members by September 30 of each year. Organizations are not required to mail the Summary of Benefits (SB) to existing members when using the combined, standardized ANOC/EOC; however, the SB must be available upon request.
D-SNPs may choose to send the ANOC for member receipt by September 30 and the EOC for member receipt by December 31; however, D-SNPs that choose this option must also send an SB with the ANOC on September 30.
The SB must include the elements described below:
- The benefits and cost sharing protections that the individual is entitled to under the State Medicaid program; and
- The specific benefits and cost-sharing protections that are covered under the D-SNP for dual eligible individuals.
For more information on general marketing guidelines and other D-SNP marketing policies, please visit the MMCM, chap. 3, which can be accessed from the Download Section below.
- Page last Modified: 02/28/2014 1:59 PM
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