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Confusion among health insurance beneficiaries about Dual Eligible Special Needs Plans (D-SNPs) is common. It is largely due to the complex interplay of Medicare and Medicaid, variability in state programs, changing nature of eligibility, and lack of information.
D-SNPs enroll individuals who are “dual eligibles“, or eligible for both Medicare and Medicaid. They offer benefits not available in traditional Medicare and generally without a premium. Dual eligibles often receive more extensive healthcare coverage and lower out-of-pocket costs, making D-SNPs a vital component of their healthcare journey.
D-SNPs offer greater coordination between Medicare and Medicaid benefits than other Medicare Advantage plans.
Medicaid, which the Federal government and states fund jointly, helps cover some Medicare costs, depending on the state and individual eligibility. Individuals may qualify for both programs by enrolling in Medicare first and then qualifying for Medicaid, or vice versa.
Dual eligibles must be 65 years or older or have a qualifying disability. They must also meet the income and asset requirements for Medicaid in their state.
What are the 4 Types of Medicaid, and What Medicaid programs are available to Medicare-eligible persons?
Dual-eligible individuals rely on Medicare for their primary health insurance coverage, which state Medicaid programs supplement with additional assistance. That leads to the question, “What are the different levels of Medicaid?”
Here are the four types of Medicaid dual eligibles can access.
1. Aged, Blind, and Disabled (ABD) Medicaid eligibility: ABD Medicaid provides coverage for a broad range of health services, including doctors’ visits, hospital care, and medical equipment if
- You are 65+, blind, or have a disability,
- And you meet the financial eligibility requirements.
Medicare and Medicaid often collaborate to cover healthcare costs. Medicaid covers services not included in Medicare, like transportation to medical appointments, certain dental services, and additional home care.
You can apply for Medicaid even if your income and assets exceed your state’s ABD Medicaid guidelines. That’s because:
- Certain kinds of income do not count (such as what you pay for health insurance), and all states exclude at least $20 of monthly income.
- Household income limits may be higher if there are more than two people in your household.
- The first $65 of your monthly earned income is not counted, and only one-half of your monthly earned income (after the initial $65 deduction) counts towards Medicaid eligibility.
Certain states provide a Medicaid spend-down program for individuals whose incomes exceed their state’s eligibility requirements. It lets you deduct medical expenses and certain healthcare costs from your income. Reach out to your local Medicaid office to check if your state offers this option.
2. HCBS: Medicaid “home and community-based services” allow people to receive long-term services and support in their own home or community rather than in an institution.
All states offer Medicaid HCBS waiver programs that supplement the limited home health care coverage under Medicare. The Medicaid HCBS waiver can cover services like:
- Personal care
- Homemaker services
- Case management
- Adult daycare
- Skilled nursing care
- Therapy services
- Home modifications
- Respite care
- Help with chores
3. Institutional Medicaid: Institutional Medicaid is available in all states and covers individuals who need nursing home or long-term care. It covers general health services and nursing home care, including room and board, nursing care, personal care, and therapy.
To qualify for Institutional Medicaid, you must require a nursing home level of care, meet nursing home functional eligibility criteria, and have income and assets below state guidelines.
4. Medicaid Excess Income Program: Also known as the Medically Needy Program or “spend-down” program, this plan helps individuals with incomes above standard Medicaid limits.
Here’s how it works.
If your income exceeds the eligibility threshold, you can “spend down” the excess income by deducting medical expenses such as bills and prescription costs. You qualify for Medicaid for the remainder of the usually six-month spend-down period if your income falls below the eligibility threshold after deductions.
In such cases, you receive full Medicaid and ABD benefits for the remainder of the period. Coverage includes doctor visits, hospital care, and medical equipment based on state guidelines.
How can I Enroll in a D-SNP?
Enrolling in a D-SNP involves meeting specific eligibility criteria and following straightforward steps. You must qualify for both Medicare and Medicaid and live in the plan’s service area.
Use the Medicare Plan Finder tool or contact your State Medicaid office to find a D-SNP. While some individuals may be automatically enrolled through passive enrollment, not all states or plans offer this option.
Contact CoverRight today to explore how D-SNPs can benefit you and find the right Medicare plan for your needs.
Frequently Asked Questions
Does Medicare or Medicaid pay costs first?
Under D-SNP coverage, Medicare is the primary payer for covered services while Medicaid is the secondary payer. That means Medicare pays for your healthcare costs first, while Medicaid covers some or all remaining costs like copayments, coinsurance, and deductibles.
2. Is Medicaid free if I am on Medicare?
Depending on your income and resources, Medicaid can help cover some costs not covered by Medicare, such as premiums, copayments, coinsurance, and deductibles. While Medicaid itself is generally free or low-cost for those who qualify, the exact coverage and costs can vary by state.
