Dual Special Needs Medicare plans provide extensive financial and health care quality benefits for qualified seniors who are living on a limited income. These Dual Special Needs (D-SNP) plans serve individuals who are either:
- Living in an institutions such as a nursing home or who require nursing care at home, or
- Eligible for both Medicare and Medicaid, or
- Have chronic or disabling conditions such as diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia
Special Needs Plans Save Money
The goal of Dual Special Needs Medicare plans is to reduce the cost of quality health care while also coordinating hospital, medical, prescription drug and other benefits.
Dual Special Needs Medicare enrollment provides members with:
- One comprehensive provider network
- Timely coordination of care
- Easier access to specialists
- Help paying for Medicare costs
- Better health outcomes
Are You Eligible For a Dual Special Needs Medicare Plan?
To be dual eligible, you must:
- Be at least 65 years old or have a qualifying disability
- Be a U.S. citizen or permanent legal resident
- Be eligible for benefits through Social Security or Railroad Retirement
- Meet low-income requirements for individuals and families
Two Coverage Levels
There are two levels of coverage for dual eligible beneficiaries:
- Full dual eligible individuals receive full Medicaid benefits and are also enrolled in Medicare.
People who are full dual eligible typically receive Supplemental Security Income (SSI) benefits, which provide cash assistance for basic food and housing needs.
Qualifying for full dual eligibility is based on both your income and your assets.
- Partial dual eligible individuals receive help from Medicaid with paying Medicare costs including premiums, coinsurance and deductibles. Partial dual eligible individuals fall into one of four eligibility categories for Medicare Savings Programs:
QMB – The Qualified Medicare Beneficiary program (QMB) helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.
SLMB – The Specified Low-Income Medicare Beneficiary (SLMB) program helps pay for Medicare Part B premiums.
QI – Like the SLMB program, the Qualifying Individual (QI) program helps pay for Part B premiums.
QDWI – The Qualified Disabled Working Individual (QDWI) Program helps pay for the Medicare Part A premium for people who meet one of the following criteria:
- Have a disability but are still working
- Lost their premium-free Part A coverage when they returned to work
- Are not receiving medical assistance from their state
- Meet income and resource limits
Chronic Special Needs Medicare
Chronic Special Needs Medicare (C-SNP) plans are D-SNP plans that restrict enrollment to individuals with specific severe or disabling chronic conditions. Approximately two-thirds of Medicare enrollees have multiple chronic conditions requiring coordination of care among primary providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive ancillary services related to diagnostic testing and therapeutic management.
The Centers for Medicare and Medicaid Services (CMS) defines severe or disabling chronic conditions as:
- Chronic alcohol and other dependencies
- Autoimmune disorders
- Cancer (excluding pre-cancer conditions)
- Cardiovascular disorders
- Chronic heart failure
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
- Severe hematologic disorders
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Neurologic disorders
For more information about qualifying chronic conditions, visit Medicare.gov.
Institutional Special Needs Medicare
An Institutional Special Needs plan is a category of Dual Special Needs plans that provide health insurance for people who are institutionalized in a nursing home or require nursing care at home.
When Can You Join a
Dual Special Needs Plan?
You can sign up for a D-SNP Medicare plan during your first Medicare enrollment period (the month you turn 65 and the 3 months before and after that month).
If you already have Medicare, you can sign up during the open enrollment period (October 15 through December 7).
You may also be able to join a plan during a Special Election Period if:
- You are diagnosed with a severe or disabling condition
- You move into a nursing home or require skilled nursing care at home
- You qualify for Medicaid
- You move into a new Special Needs Plan service area
- Your Special Needs Plan leaves the Medicare program
You can sign up for a Chronic Special Needs plan at any time upon being diagnosed with a chronic condition.
Before you can join a Chronic Special Needs plan, your doctor must complete a chronic condition verification form at the time of your enrollment. Your insurance agent will provide you with the form and your doctor can complete and return it to verify your eligibility.
Do You Qualify For A Dual
Special Needs Medicare Plan?
Dual Special Needs Medicare plans provide extensive financial and health care quality benefits for qualified seniors. Find out if you qualify by clicking on the GET HELP button at the bottom of this page.