In our ever-changing Medicare market, we have an emerging demographic that is significantly underrepresented – Dual Eligibles. Approximately 12 million Americans are ‘Dual Eligible’, representing 20% of the Medicare population. 1
Less than 30% of those Dual Eligibles are enrolled in a Medicare Advantage or Special Needs Plan (D-SNP). This reality has created a surge of Special Needs Plans being offered and a renewed focus on this unique demographic from Medicare Advantage carriers nationwide.
If you are an independent agent offering Medicare plans you should be exploring the Dual Eligible/Special Needs Plan market. D-SNPs have unique enrollment windows and guidelines compared to standard MAPDs, which yield a year-round selling opportunity outside of AEP and OEP for agents.
A Dual Eligible Special Needs Plan - or D-SNP for short - is a special type of Medicare Advantage plan that provides health benefits for people who are “dual eligible,” meaning they qualify for both Medicare and Medicaid.
States determine which D-SNP's can be offered and the benefits provided. Generally speaking, D-SNP’s may include: (Verify plan coverage with carrier)
A D-SNP plan will include coverage for hospital services (Medicare Part A), medical health care needs (Medicare Part B), and prescription drugs (Medicare Part D) through a single plan. With a D-SNP there may also be social services available to help coordinate a beneficiaries Medicare and Medicaid benefits.
A D-SNP is commonly confused with a Medicare Advantage Medicare-Medicaid Plan (MMP). Unlike a D-SNP, MMPs only serve full benefit dual (Medicare/Medicaid) eligible beneficiaries and some additional limitations may apply (such as state-specific requirements).
MMP's were introduced in 2014 and are only offered in a few counties across the country.
There are five D-SNP types with varying degrees of Medicaid coverage:
We’ll describe these in more detail below.
To be eligible, an individual must be qualified for both Medicare and Medicaid.
To qualify for Medicare, an individual must be 65 years old or older or have a qualifying disability.
To be eligible for Medicaid, an individual’s income and asset level must fall below certain thresholds determined by their state.
The Dual Eligible Special Needs Plan (D-SNP) was developed to address this group. Below are a few aspects of the dual eligible group:
Dual eligible beneficiaries fit into one of the seven categories of Medicaid eligibility. States may vary in determining their eligibility categories so there may be State-specific differences in the eligibility categories. The general Medicaid eligibility categories include the following:
The Chart below shows eligibility for D-SNP types based on Medicaid categories:
*Special Needs Plans are not available everywhere in the United States. Talk to one of our experienced marketers with any questions about these or other plans.
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.
A full-benefit D-SNP enrolls individuals who are eligible for:
Medical assistance for full Medicaid benefits for the month under any eligibility category covered under the Medicaid State Plan or comprehensive benefits under a demonstration under Section 1115 of the Act; or, Medical assistance under Section 1902(a)(10)(C) of the Act (Medically Needy) or Section 1902(f) of the Act (States that use more restrictive eligibility criteria than are used by the SSI program) for any month if the individual was eligible for medical assistance in any part of the month.
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 / Medicare Zero Cost Sharing D-SNPs:
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).
Fully Integrated Dual Eligible Special Needs Plans:
Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs), a special type of D-SNP, were authorized by the Affordable Care Act (ACA) in 2010 to achieve a high degree of integration of Medicare and Medicaid services. The use of FIDE SNPs is much more limited than the above mentioned types.
FIDE SNPs must meet several specific requirements, the most important of which is that they must contract with the state for coverage of Medicaid long-term care benefits and services, consistent with state policy, under risk-based financing.
They must also coordinate the delivery of Medicare and Medicaid health and long-term care services. Only 11 percent of all D–SNPs (45 of 393 plans) are FIDE SNPs. For more information see chap. 16b, section 40.4.3
D-SNP eligibles can enroll during regular Medicare Advantage enrollment period or Special Enrollment Period (SEP).
The Center for Medicare and Medicaid Services ("CMS") implemented a significant change to the LIS/Dual Special Enrollment Period. Beginning January 1, 2019, beneficiaries eligible for the LIS/Dual SEP will be permitted to make a coverage change one time per quarter during the first nine months of the year: 7
The LIS/Dual SEP may not be used during the fourth quarter of the year (October - December).
The effective date of the enrollment into the new plan will be the first of the month following the receipt of an enrollment request. Per CMS guidelines, the SEP is considered "used" based on the month in which the election was made.
Using their example, if an election is made in March with an April effective, the first quarter use of the SEP would be considered "used" not the second quarter.
An SEP for individuals who gain, lose or have a change in their Dual or LIS eligibility, have a one time opportunity to make an election within three months of the change or notification of the change, whichever is later.
For those that lose Medicaid Eligibility, they have an SEP beginning the month they receive the notice of the loss of eligibility, plus two additional months to make an enrollment choice.
Keep in mind that a beneficiary can only remain enrolled in a Special Needs Plan for as long as they meet the eligibility criteria of that plan.
If their situation changes and they no longer meet the enrollment requirements for the Special Needs Plan, they will get a Special Election Period to switch to a different Medicare Advantage plan or return to Original Medicare.
They also have an SEP allowing them to change their D-SNP once during each of the first three calendar quarters of the year.
All of this information can understandably be confusing for your clients. As an agent, your ability to help them understand and weigh their options will decide how loyal a client they become.
Prospects for D-SNPs are likely to reside in urban or other low-income areas.
They will likely depend on Welfare and Social Security payments and you can use that to inform your search.
When you look may be as important as where you look. Here are a few suggestions to get you started.
First half of the month:
Second Half of the Month:
Throughout the Month:
Bear in mind that this group of prospects may have numerous challenges in their lives, and will likely take more work on your part to help them understand all of the benefits of a D-SNP.
At the end of the day, those agents that genuinely want to help them are going to be the ones that will perform best in this market.
Tear off flyers and business cards won’t hurt, but it’s going to take more than that to connect with this group. You will need to have boots on the ground to engage with these prospects. They will need more guidance and explanation than other populations.
You will need to spend time with them, where they are. That may be a difficult thing, or a positive experience, depending on the attitude you bring to the job.
If you don’t mind the idea of setting up a booth at community events, or visiting community centers or food banks to help out, then the D-SNP market may be a great way to add to your business.
According to CMS rules (MMG Appendix 2), the following disclaimer must be used on all D-SNP marketing materials that mention cost-sharing information to residents in the United States: Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
This disclaimer is not required on material for beneficiaries who live in the territories.
Dual Eligible beneficiaries can join or switch D-SNPs more often than other plans, so a human touch is required.
They will need to know you have their best interest in mind and that you can genuinely help them. At the end of the day it’s not rocket science.
Like any group of customers, the only way to keep them from moving their business elsewhere is by taking good care of them.
D-SNPs can be a great way to grow your business all year round. By being a go to resource on special needs plans you will be rewarded by a loyal group of clients.
[ This information intended for agent use only ]