A Medicare Dual Eligible Special Needs Plan (D-SNP, pronounced “dee-snip”) is a type of Medicare Advantage plan made for people who fall into the neediest of populations. D-SNPs allow people with Medicare and Medicaid to cover out-of-pocket costs that would otherwise be unaffordable to them. Medicare Advantage plans, otherwise known as Medicare Part C, are private fee-for-service, value-based care or specialty care plans that cover a variety of health care services not covered in Medicare Parts A and B.

Who is Eligible?

To be eligible for any Medicare Advantage plan, the beneficiary must already be enrolled in Medicare Parts A and B. To furthermore be eligible to enroll for a D-SNP, the insured must be enrolled in both the federally-run program Medicare and the state-run program Medicaid.

Some 12 million Americans are entitled to both Medicare and Medicaid coverage based on their being over 65, having little or no assets and income and having certain qualifying health conditions. Many of these individuals may qualify for a D-SNP.

What the plans include

One the most complex health insurance plans on the market, D-SNPs have coverage and eligibility requirements that are often difficult for laypeople to navigate. However, for many elderly people who cannot cover the financial costs of healthcare, D-SNPs offer the most comprehensive benefits of any other health plan.

The features of a D-SNP typically include:

No monthly premium
Care coordination between healthcare providers
Prescription drug coverage (via Medicare Part D)
Access to several over-the-counter supplies and medications
Transportation to medical appointments
Telehealth via Zoom or similar service
Vision and hearing benefits
“Silver Sneakers” fitness and gym memberships
Low or no copays

Medicare pays for a share of your medical costs first, then Medicaid pays for any costs that may be left over. As such, Medicaid is the so-called “second payer” for costs that are not covered or only partially covered by Medicare.

While federal law sets Medicaid income standards, each state has its own Medicaid eligibility and coverage limits. Plan coverage varies by state, but there are some plans that include all Medicare and Medicaid benefits.

“…Medicaid is the so-called ‘second payer’ for costs that are not covered or only partially covered by Medicare.”

There is a variety of D-SNPs available. These can be HMO (Health Maintenance Organization) plans or PPO (Preferred Provider Organization) plans. Plan details vary by state and county and range in terms of cost.

When can someone enroll?

Every citizen and legal resident of the US becomes eligible for Medicare when they turn 65. There is a period starting three months before and three months after the month one turns 65 years old to enroll for initial Medicare coverage.

The elderly are not the only population that is eligible for Medicare. Younger applicants with certain conditions or disabilities, and those who have been on Social Security Disability Insurance for 24 months or more all qualify.

Eligibility for Medicaid involves a different set of factors. These include primarily applicants’ income and assets as well as their current medical conditions. Another factor is whether an applicant qualifies for Supplemental Security Income.

Once someone is enrolled in both Medicare and Medicaid, that person may be eligible to enroll in a D-SNP. Enrollments occur during the Medicare enrollment period (typically October 15th to Dec 7th), the Medicare Advantage enrollment period (January 1st through March 31st) and at various other times of the year depending on certain changes in the applicant’s life.

The following documents are needed for a D-SNP enrollment:

a Medicare card
a Medicaid card
the exact date that Medicare parts A and/or B coverage started

The challenge of qualifying for Medicaid

While Medicare is available to all people over the age of 65, Medicaid is specifically designed to accommodate the healthcare and long-term care needs of the indigent. That means that people with considerable assets and income are typically excluded from the program. However, there are ways for Florida residents to spend down their assets, pass assets to the next generation and generally protect some of their income and still be eligible for Medicaid. The complexities of the application, the eligibility requirements and the assessment of assets make it easier if applicants work with an experienced elder law or estate planning attorney during the process.

The importance of an attorney

A Medicaid application can be overwhelming to applicants who have never completed the process before. For those with assets and some income, concepts such as the “five-year lookback period” and “community spouse” can be bewildering. In Florida, because the intricacies of Medicaid planning require a knowledge of the law, only a lawyer is legally qualified to advise applicants on the process.

In fact, legal fees typically form part of the so-called Medicaid spend-down period. Applicants who do not hire a lawyer early in the process often regret not doing so. If a problem arises after the assets and income of early retirement have already been spent down, there may not be enough left money to hire a lawyer.

South Florida Law

South Florida Law is a full-service estate planning, business and real estate law firm that can assist families in employing a variety of strategies during Medicaid means-testing to become Medicaid eligible. We can also proactively work with families, couples and individuals to protect their homes from Medicaid’s estate recovery program. The best time to begin planning for Medicaid is years before nursing home services are needed. Contact us today for a consultation by calling (954) 900-8885 or via our contact form.