This is the first of a three-part blog series about operational strategies for Dual Special Needs plans (D-SNPs), which has been an emphasis and expansion topic for both CMS and individual states. This segment focuses on the scope of D-SNPs, eligibility requirements and enrollment process.
To begin, we need to understand what encompasses a D-SNP. Medicare allows certain categories of covered individuals to enroll in Medicare Advantage “Special Needs Plans” (SNPs) that address their particular care situations. SNP plans offer more generous coverage than regular Medicare Advantage plans or “Traditional Medicare” fee-for-service (FFS). One type of SNP is designed for Medicare enrollees whose limited income and assets make them eligible for additional Medicaid benefits. These individuals are referred to as “dual eligibles” and can enroll in Dual Special Needs Plans (D-SNPs) that provide extensive medical and long-term care coverage.
Dual eligibles receive both types of coverage because:
There are numerous categories of dual eligibles, but only some of them qualify to enroll in a D-SNP.
Other categories of dual eligibles are those with higher income who are ineligible for D-SNPs because they only receive Medicaid subsidies for their Medicare premiums, rather than benefits under both Medicare and Medicaid.
There are three types of D-SNP plans approved by CMS. Enrollment in these plans is dependent on the category of the individual and state guidelines.
D-SNP Type |
Who can enroll |
Fully Integrated Dual Eligible (FIDE) SNP Covers Medicare and Medicaid benefits under a single legal entity offering both Medicare medical and mental health benefits; and Medicaid primary, acute care and LTSS |
QMB+ and SLMB+ |
Highly Integrated Dual Eligible (HIDE) SNP These plans have a higher level of integration than a typical D-SNP. Covers Medicare and Medicaid benefits under a single legal organization but with Medicaid benefits provided by a separate plan entity controlled by the D-SNP’s parent organization, which must coordinate with the D-SNP. |
QMB+ and SLMB+ |
Coordination Only (CO) D-SNP Meets minimum CMS requirements to hold a contract with a state to coordinate state information-sharing requirements. For example, when a CO D-SNP enrollee enters a hospital, the D-SNP must notify the state Medicaid program. Typically, CO D-SNPs only provide Medicare coverage, with Medicaid benefits separately provided by the state or another health plan. |
QMB and QMB+ |
It’s important to note special rights and options regarding enrollment that are exclusively available to dual eligibles. These factors amplify the pressure on D-SNPs to maintain high levels of customer service, member satisfaction and competitive provider networks.
Attracting and retaining dual eligible members can be challenging for D-SNPs, but enrolling is easier in states where CMS grants authority for direct enrollment using a Default Enrollment or Exclusively Aligned Enrollment process.
D-SNPs and even standard Medicare Advantage plans have the responsibility to confirm and monitor both Medicare and Medicaid eligibility of dual eligibles.
Thus, it is important for D-SNPs to track their enrollees’ eligibility re-determination status, remind them of the due dates and assist with their completion of necessary documentation.
Enrollment information for D-SNPs is primarily received from two government enrollment channels, both of which require monitoring.
D-SNPs are responsible for reconciling transactions from these two government enrollment systems on a member-specific basis, with a core requirement that the enrollee’s name, date of birth, gender and member numbers match between the two files. D-SNPs must notify both levels of government of any discrepancies, as well as other lifestyle changes when they are first known. This includes a change of address, phone number or other status changes.
Some states have active call centers and vendors that manage default plan auto-assignment and Medicaid beneficiary status and contact changes, while other states delegate enrollee status to health plans.
Because of these variables, customer service responsibilities for D-SNP plans exceed those of standard Medicare Advantage plans.
To be successful, D-SNP enrollment and customer service staff must be significantly more proactive in engaging with enrollees and their caregivers than the typical reactive health plan service model.
A key competitor for D-SNPs is the traditional Medicare and Medicaid FFS program, where coverage is directly administered by CMS or the state, and not under a single plan. Dual eligibles can be automatically enrolled in FFS. This option is preferred by many healthcare providers since it subjects clinicians to less management, care authorization, and less program coordination by the two levels of government.
However, this situation may not be in the best interest of the patient, who can experience frustrations in dealing with multiple sets of rules, benefits, ID cards and providers. Such enrollees also lack the support of a health plan that could coordinate coverage, care and requirements between the two programs.
Additionally, some states require that dual eligibles be enrolled in managed care plans for the Medicaid portion of their coverage, creating further complexity for the patient.
Download our "Integrated D-SNP vs Medicare Advantage Enrollment" comparison matrix now for a snapshot of standard Medicare Advantage enrollment vs. that for D-SNPs.
Coverage of the dual-eligible population represents an expanding opportunity for managed care plans. However, meeting beneficiaries’ needs and managing the complexities of both the Medicare and Medicaid programs can be an operational challenge. Areas of consideration for developing a clear strategy and potential investment for success:
SS&C Health offers solutions in all key functions of D-SNP and MMP operations through our expertise and technology strength. Contact us today to see how we can help your plan embrace the opportunity and succeed in serving dual eligibles.
In part 2 of our series, we’ll explore the process of claims and benefit adjudication—the importance of coordination between Medicare and Medicaid, customized benefit packages and the complexities associated with care management and integrated services for this unique population.
[1] AZ, CA, DC, FL, HI, IA, ID, IN, KS, KY, MA, MN, NE, NJ, NM, NY, OR, PA, PR, TN, TX, VA, WA, WI