Dual-Special Needs Plans: Help Your Clients Understand Them

It has been our experience that many brokers avoid selling dual-special needs plans (D-SNPs) due to their complexities—or perceived complexities, if you will. As a broker, you can help your clients overcome perceived complexity objections by also helping them understand exactly what D-SNPs are and how they work.

Be aware that the states have already begun Medicaid redetermination. This is to say that they are looking over subscribers to determine which ones are no longer eligible for Medicaid benefits. Those subscribers will be removed and will have to choose another plan. This affects everything from beneficiary subsidies to coverage. But it's your opportunity, as a broker, to help your clients enroll in either a Medicare Advantage (MA) plan—also referred to as a Medicare Part C plan or Medicare Health plan, or a Medicare Advantage Plan that includes Medicare Part D prescription drug coverage (MAPD).

Dual Eligible Basics

Explaining D-SNPs to your clients starts with the basics of dual eligibility. As you know, there are a limited number of dual eligible subscribers enrolled in both Medicare and Medicaid. Medicare eligibility is under title XVIII. They receive their federal Medicare benefits through the Centers for Medicare & Medicaid Services (CMS) while their Medicaid benefits are provided under their state programs.

Dual eligible programs are typically offered to people with:

• Limited income
• Certain types of medical conditions
• Unique medical or healthcare requirements

Given the eligibility requirements for D-SNPs, it is possible that none of your clients are affected by the ongoing redetermination process. But it's always good to have D-SNPs in your back pocket just in case. Be prepared to explain the basics so that you and your clients can determine whether they are a good solution to those being disenrolled from Medicaid.

The States Administer Medicaid

It is also important for your clients to understand that the states bare responsibility for administering Medicaid. As such, they also set their own eligibility requirements. Medicaid eligibility is generally divided into a number of categories, including:

• Full Medicaid
• Qualified Medicare Beneficiary (QMB)
• QMB Plus
• Specified Low-Income Medicare Beneficiary (SLMB Only)
• SLMB Plus
• Qualifying Individual (QI)
• Qualified Disabled and Working Individual (QDWI)

As the states redetermine Medicaid eligibility, they are looking at how certain groups of individuals fit into these categories. In some cases, people disenrolled from Medicaid will not have any option but to look at individual health insurance plans. But others will be eligible to enroll in D-SNPs.

One last thing to note in this regard is that the CMS no longer categorizes D-SNPs by sub-type category. The plans themselves have not changed all that much.

Medicare Zero-Dollar Cost Sharing

D-SNPs can come with or without a Medicare zero-dollar cost sharing provision. Brokers should know where each of their D-SNPs fall in this regard. The knowledge is critical to listing plan benefits correctly and in a way clients will understand. Also note that the CMS uses one of three codes to designate D-SNPs in relation to Medicare zero-dollar cost sharing:

• Yes (Y) – The plan has the provision.
• No (N) – The plan does not have the provision.
• 9 – The provision is not applicable to the plan.

In the case of the '9' category, you're looking at plans that are not true D-SNPs. That's just the heads-up in the rare case that you come across such a plan.

If you aren't sure about all the pertinent D-SNP details, make sure you’re working with a general agency like BenefitMall that has the senior market experience you can depend on for additional guidance. As the states re-evaluate their own Medicaid eligibility, you may run into a situation in which D-SNPs are the perfect solution to offer your clients impacted by the Medicaid redetermination process.