What is a Dual-Eligible Special Needs Plan (DSNP)?

In the United States today, there are over 12 million people who have dual-eligible healthcare benefits *. If you are eligible for both Medicare and Medicaid services, you may not be aware of the options offered by Medicare Part C Medicare Advantage plans.

Medicare Advantage plans are offered by private insurance companies who contract with Medicare. They are required to provide the same Part A and Part B coverage as Original Medicare, but most Medicare Advantage plans include additional benefits, like vision, dental care, fitness club memberships, or even prescription drug coverage. If you qualify for both Medicare and Medicaid, you may enroll in a Medicare Advantage Special Needs Plan (SNP) designed specifically for dual-eligibles if a plan is offered in your area.

Dual-eligible Special Needs Plans are sometimes called DSNPs. DSNPs work with your state medical assistance program and may provide access to the quality healthcare you deserve at a price you can afford. Dual-eligible beneficiaries enrolled in Medicare and Medicaid are generally considered to be at a higher risk for chronic illness due to social risk factors, so your healthcare coverage can be even more important.

What is a Dual-eligible Special Needs Plan (DSNP)?

DSNPs are special types of Medicare Advantage plans that limit membership dual-eligible beneficiaries. Most DSNPs are categorized as HMOs (Health Maintenance Organizations), but some are PPOs (Preferred Provider Organizations). HMO plans will usually require you to choose a primary care physician from their network of medical providers, and you will need to get a referral from that doctor before seeing a specialist. If you enroll in a PPO plan, you can likely visit any doctor within the plan’s network without a referral and you have the option of going outside the network for a higher out-of-pocket cost.

There are five types of DSNPs:

• All-Dual
• Full-Benefit
• Medicare Zero Cost Sharing
• Dual Eligible Subset
• Dual Eligible Subset Medicare Zero Cost Sharing

The type you can enroll in is determined by the degree of your eligibility for state medical assistance. 

Who is eligible for a DSNP?

You are eligible to enroll in a DSNP is you qualify for both Medicare and state medical assistance coverage (Medicaid). While Medicare eligibility is based on age or disability, enrollment in Medicaid is based on having a lower income and limited resources.

To qualify for Medicare benefits you must be a United States citizen or have been a legal resident for at least five years. You must be 65 years old or have a qualifying disability if you are younger than 65.

To qualify for a state-run medical assistance program, your income level must not exceed your state of residence’s income threshold. You must also be a United States citizen or meet other immigration qualification requirements, reside in the state where you apply, and have a Social Security number. 

In some states, you must meet one of the following requirements:

• Be at least 65 years old
• Have a permanent disability according to SSA definitions
• Be blind
• Be a pregnant woman
• Be a child, parent or caretaker of a child

What do DSNPs cover?

DSNPs are also only available to dual-eligible beneficiaries. All DSNPs provide the same coverage that beneficiaries have through their Original Medicare benefits and Medicaid services, and include prescription drug coverage. Individual states and carriers determine what additional benefits these plans can offer.

In general, many plans include the following additional benefits:

• Low or $0 monthly premiums
• Care coordination and management
• Vision or hearing care
• Dental care 
• Over-the-counter allowance
• Transportation to and from medical appointments
• Telehealth services
• Fitness program membership
• Prescription drug coverage (Part D)
• Routine foot care
• Chiropractic care

Because these benefits vary by plan, it is important that you ask your DSNP insurance provider what benefits are included in the plan before you sign up.

When can you enroll in a DSNP?

You can enroll in a DSNP during the regular Medicare Advantage enrollment periods which include the following:

• Your Initial Enrollment Period (IEP). This is a seven-month long period that includes three months prior to your 65th birth month, your birth month, and the three months that follow your 65th birth month. This also applies if you have been receiving Social Security disability benefits or Railroad Retirement Board benefits for 24 months. Your IEP would be the three months prior to the 25th month of receiving benefits, the entire 25th month, and the following three months.

• The Part B Special Enrollment Period (SEP)

• The General Enrollment Period (GEP) which runs between January 1 and March 31 every year.

• The Annual Enrollment Period (AEP) which runs from October 15 to December 7 every year.

With a Dual-eligible Special Needs Plan you get all the benefits of your state and federal healthcare programs plus additional benefits and services for greater choice and flexibility in medical care. If you feel you qualify for a DSNP, compare options available in your area before enrolling.

*​​She has Medicare and Medicaid. So why should it take 18 months to get a wheelchair? / npr.org