Overview
This FAQ doc solutions frequent questions from advisors and advocates who’re helping people enrolled in each Medicare and Medicaid (“dually eligible people”) who’re contemplating their well being plan choices. It’s a companion to Justice in Growing older’s transient Twin-Eligible Particular Wants Plans: What Advocates Must Know (“D-SNP fundamentals transient”) and webinar.
What’s a D-SNP?
Twin-Eligible Particular Wants Plans (D-SNPs) are a sort of Medicare Benefit well being plan designed to serve dually eligible people. D-SNPs are plans run by personal insurance coverage firms who contract with the Facilities for Medicare & Medicaid Companies (CMS) to offer Medicare (and generally Medicaid) advantages by managed care. All D-SNPs are required to coordinate an enrollee’s Medicare advantages with their Medicaid advantages to some degree see Query #8 for extra info on integration necessities.
Are D-SNPs out there in each state?
At the moment, D-SNPs can be found in 46 states and the District of Columbia (D-SNPs are usually not presently out there in Alaska, Illinois, New Hampshire, or Vermont). D-SNP availability rely partly on an individual’s county or zip code. People can see the D-SNPs out there of their space by accessing the Medicare Plan Finder.
Enrolling in a D-SNP
Are dually eligible people required to affix a D-SNP?
No. Dually eligible people can select between Conventional Medicare (additionally typically known as unique or fee-for-service Medicare), Medicare Benefit well being plans, and (in most states) the Program of All-Inclusive Take care of the Aged program (PACE). Some states mechanically enroll some dually eligible people into D-SNPs after they change into Medicare eligible, however the correct to choose out or disenroll stays. See Query #7 for extra particulars on automated enrollment.
Ought to a dually eligible particular person be a part of a D-SNP?
The choice to affix a D-SNP is a person one primarily based on an individual’s well being care wants and supplier preferences, the D-SNP’s community of contracted suppliers, prescription drug availability, and different concerns. This is usually a difficult alternative. Talking with a free, unbiased State Well being Insurance coverage Program (SHIP) counselor, reviewing plan supplies, and utilizing the Medicare Plan Finder are methods to assist your shopper evaluation their choices and make the enrollment alternative that’s finest for them.
Can a partial-benefit dually eligible particular person be a part of a D-SNP?
A partial-benefit dually eligible particular person is an individual who’s enrolled in a Medicare Financial savings Program (e.g., Certified Medicare Beneficiary, Specified Low Earnings Medicare Beneficiary, or Certified Particular person) solely and are not additionally enrolled in full Medicaid. Medicare Financial savings Applications are a sort of Medicaid program that gives monetary help by paying Medicare out-of-pocket prices together with premiums, co-pays, and co-insurance. They don’t present the total vary of Medicaid advantages, resembling physician visits, hospital stays, private care providers, long-term care in nursing facility, or different advantages.
A full-benefit dually eligible particular person is an individual who’s enrolled in Medicare and full Medicaid, whether or not or not they’re additionally enrolled in a Medicare Financial savings Program.
In most states, partial-benefit dually eligible people can enroll in a D-SNP (and in a few of these states, separate D-SNPs are supplied only for partial-benefit dually eligible people).1
Every D-SNP is required to contract with the state by which it operates; this contract known as a State Medicaid Company Contract (SMAC) and is usually public. A SMAC will include info on which populations are eligible to enroll in a D-SNP. You too can contact your shopper’s state Medicaid company or the plan to get readability on D-SNP eligibility for partial-benefit dually eligible people
Can an individual in “spend-down” or “share of value” Medicaid be a part of a D-SNP?
States decide which Medicaid enrollees are eligible for enrollment in a D-SNP. This contains whether or not an individual who’s medically needy (also called “spend-down” or “share of value”) is eligible for enrollment in a D-SNP. This info is usually out there in a state’s SMAC. Advocates can discover out extra by contacting their shopper’s state Medicaid company or the D-SNP.
If an individual loses free Medicaid and is assessed a spend-down or share of value, they’ll now not be eligible for his or her D-SNP if full Medicaid is required for enrollment. D-SNPs in some states might have “deeming intervals” that act as a brief grace interval retaining people enrolled within the D-SNP. This deeming interval gives time for the person to try to repair or restore their Medicaid eligibility. See Query #18 for extra particulars.
Are individuals mechanically enrolled right into a D-SNP? What protections can be found?
An individual could be mechanically enrolled in a D-SNP in some circumstances by “default enrollment.” Folks on Medicaid who change into newly eligible for Medicare, both by age or incapacity, could be enrolled in D-SNPs by default enrollment. That is the way it occurs: An individual enrolled in a Medicaid managed care plan after they change into eligible for Medicare could also be defaulted, or mechanically, enrolled into the D-SNP that’s affiliated with their Medicaid managed care plan. Plans should ship written discover earlier than automated enrollment takes place and the particular person has the correct to choose out. With a view to choose out, your shopper should make the affirmative option to cancel the default enrollment earlier than it’s efficient.
Not all D-SNPs or states have default enrollment in place.2 For extra info on default enrollment, see Justice in Growing older’s D-SNP fundamentals transient.
Accessing details about D-SNP Integration and Obligations
How can an individual discover out what degree of integration a D-SNP has?
Various kinds of D-SNPs have completely different ranges of duties in terms of integrating Medicare advantages with Medicaid advantages, together with care coordination, communications, and grievances and appeals. D-SNP classes are Absolutely Built-in (FIDE), Extremely Built-in (HIDE), or coordination-only (CO D-SNP). Every of those classes may also have an Relevant Built-in Plan (AIP) designation. It’s useful to know what sort of D-SNP an individual is enrolled in to know what duties and coordination the D-SNP is obligated to offer to its enrollees. Extra info on these integration designations is offered in Justice in Growing older’s D-SNP fundamentals transient.
It’s not all the time simple to determine a D-SNP’s integration degree. Typically FIDE and HIDE designations are included within the plan’s title on Medicare Plan Finder or on the plan’s web site supplies (although typically, these supplies don’t specify the kind of D-SNP a plan is). You may think about calling the plan and asking in regards to the plan’s integration degree. CMS additionally releases Particular Wants Plan (SNP) month-to-month knowledge on Particular Wants Plans. It’s out there as an excel doc, and contains every plan title, the state it’s in, and whether or not it’s a FIDE, HIDE, or CO D-SNP. Be aware that it might be exhausting to match the data from the Medicare Plan Finder to the SNP month-to-month knowledge.
How can an individual discover state necessities for D-SNPs?
A state’s SMAC can include a wealth of knowledge, together with eligibility standards for enrollment into the D-SNP, further care coordination necessities, and expectations round member communications. Some states publicly submit their SMAC’s on-line however most don’t. Accessing a state’s SMAC could be troublesome. We’ve listed some examples of public SMACs within the Appendix. Advocates can strive asking their Medicaid company for a duplicate of their state SMACs. For extra info on SMACs, see Justice in Growing older’s D-SNP fundamentals transient.
D-SNP Advantages, Supplier Networks, and Prices
What advantages do D-SNPs provide?
D-SNPs are required to supply Medicare Half A (hospital/inpatient), B (outpatient), and D (prescription drug) advantages. D-SNPs typically provide supplemental advantages that aren’t supplied underneath Unique Medicare, together with imaginative and prescient, dental, listening to, transportation, and flex playing cards. Please notice that Medicaid typically covers many objects which might be additionally supplied as supplemental providers by a D-SNP. D-SNPs plan supplies, together with the Proof of Protection, will record the providers supplied by the D-SNP.
One factor to look out for is whether or not the shopper’s supplier or provider is enrolled within the D-SNP, which may have an effect on whether or not Medicare or Medicaid will cowl the service. See Query #14, beneath, for extra details about out there suppliers.
What care coordination will a D-SNP provide?
D-SNPs should comply with their mannequin of care, which should embody an outline of how the D-SNP will coordinate look after enrollees.3 A state’s SMAC might embody extra care coordination necessities, together with necessities for the D-SNP to interact in discharge planning from a hospital or nursing facility say, and to include extra parts in its well being threat evaluation for the person. The Built-in Care Useful resource Heart just lately revealed pattern care coordination language it present in varied state SMACs.
Plan supplies (together with the Proof of Protection) might, however don’t all the time, include info on the care coordination supplied by a plan. Advocates can strive contacting their shopper’s state Medicaid company to acquire extra details about care coordination supplied by D-SNPs.
What prices are related to a D-SNP?
Generally, a dually eligible particular person shouldn’t be charged premiums, co-pays, or co-insurance, in Conventional Medicare or in a D-SNP. In sure circumstances, a D-SNP might cost a further premium for providing extra providers. If a person accesses non-covered providers, or goes to a supplier that isn’t enrolled in Medicare or Medicaid, there may additionally be related prices.
Suppliers generally cost dually eligible people for providers improperly. For extra info, see Justice in Growing older’s Improper Billing Toolkit.
Does your shopper need to get prior authorization from a D-SNP?
Sure, your shopper might have to get prior authorization, relying on the service they’re searching for. Prior authorization, or prior approval, is a component of a D-SNP. Members should get prior authorization from the D-SNPs for a lot of well being providers earlier than therapy is offered. A plan’s Proof of Protection can embody info on which providers could also be topic to prior authorization.
One factor to look out for when switching plans is whether or not a previous authorization approval will comply with your shopper to the brand new plan, and the way lengthy it’s going to final. In some circumstances, the approval can keep in place for months after the swap.
What well being care suppliers can be found in a D-SNP?
One key distinction between Conventional Medicare and a D-SNP is that enrollees are required to see suppliers which might be contracted with the well being plan or agree to simply accept cost from the plan. The D-SNP supplier listing will embody the record of suppliers members can see for his or her care. The listing can be out there on the plan’s web site or in print.
It may be the case, nevertheless, that the supplier listing is outdated, or that listed suppliers are usually not accepting new sufferers. For suppliers which might be vital to a shopper, it could be a good suggestion for them to contact that supplier earlier than switching plans.
What drugs does a D-SNP cowl?
Medicare Plan Finder features a software which permits people to enter within the drugs that they want their plan to cowl. They’ll then search D-SNPs to search out their drugs and community pharmacies. A D-SNP’s Half D formulary can be listed on-line. 1-800 Medicare and SHIP counselors are additionally a great useful resource to find out which D-SNPs embody protection for his or her pharmaceuticals.
How will enrolling in a D-SNP have an effect on an individual’s Medicaid advantages?
An individual will proceed to maintain their Medicaid advantages whereas enrolled in a D-SNP. Some D-SNPs, resembling FIDE SNPs, might embody protection and supply of Medicaid advantages. All D-SNPs are required, at some degree, to coordinate their enrollee’s Medicaid advantages. Appendix B of Justice in Growing older’s D-SNP fundamentals transient gives a desk explaining how completely different sorts of D-SNPs are required to supply several types of Medicaid advantages.
One factor to look out for when contemplating a shopper’s enrollment right into a D-SNP is when a shopper is enrolled in 1915(c) house and community-based providers (HCBS) waiver. Some states and D-SNPs limit enrollment for people who find themselves enrolled in 1915(c) HCBS waivers. Advocates ought to verify with the D-SNP or state in order that their shoppers don’t inadvertently jeopardize their 1915(c) providers by becoming a member of a D-SNP.
Leaving a D-SNP
How can an individual depart a D-SNP?
There are numerous occasions of yr {that a} dually eligible particular person can depart a D-SNP:
- Anybody can depart a Medicare Benefit plan, together with a D-SNP, from January by March every year.
- Dually eligible people have an possibility, as soon as per quarter, to disenroll in a D- SNP and be a part of Conventional Medicare (together with enrolling in a Half D plan). You’ll find out extra details about choices to disenroll from or change Medicare Benefit Plans on this CMS web site. Beginning in January 2025, dually eligible people may have an choice to disenroll on a month-to-month (quite than quarterly) foundation in sure circumstances.
- Since D SNPs are a sort of Medicare Benefit plan, different Particular Enrollment Intervals round disenrolling from or switching Medicare Benefit plans can apply.
Are their conditions the place an individual loses membership in a D-SNP? What protections can be found?
An individual could be disenrolled from the D-SNP in the event that they now not meet the enrollment standards. This contains transferring to a service space not lined by the D-SNP or if Medicaid advantages are discontinued. Some D-SNPs provide a “deeming interval,” which maintains D-SNP enrollment if an individual loses full Medicaid. An individual is “deemed” eligible for a brief time period. Deeming intervals can final thirty days to 6 months, relying on the plan. Deeming gives continued entry to D-SNP suppliers and D-SNP offered care. If an individual restores their Medicaid eligibility earlier than the deeming intervals ends, they won’t be disenrolled.
Deeming is optionally available and never all states or D-SNPs have deeming intervals. Medicaid advantages will not be lined throughout the deeming interval. To search out out if deeming is obtainable, enrollees can ask their D-SNP if they provide a deeming interval and for a way lengthy. The State SMAC, if publicly out there, may also include this info if a D-SNP gives deeming.
Appendix: Examples of Public State Medicaid Company Contracts
Every D-SNP sponsor should enter right into a contract with the state by which the D-SNP operates. These contracts are known as State Medicaid Company Contracts (SMACs). Beneath is a pattern of SMACs which might be public. Many of those SMACs have been collected by the Built-in Care Useful resource Heart. For extra details about matters that SMACs handle, see the ICRC’s useful resource on pattern SMAC language.
The SMACs listed beneath will not be the hottest variations out there.
Arizona
2023 Arizona Well being Care Price Containment System Medicare Benefit Group Settlement
California
2024 California Division of Well being Care Companies Completely Aligned Enrollment D-SNP Contract
Florida
State of Florida Company for Well being Care Administration Commonplace Contract
Indiana
Iowa
Contract between Iowa Division of Human Companies and Amerigroup Iowa, Inc.
Massachusetts
Massachusetts’ Second Amended and Restated Contract for Senior Care Organizations
Minnesota
New Jersey
New Jersey Mannequin MIPPA Contract
Pennsylvania
Rhode Island
Tennessee
Virginia
Washington State
Washington State Amended and Restated State Medicaid Company Contract (January 1, 2024)
