In our previous article, we established the foundation of Medicare Savings Programs and their eligibility requirements. Now we'll connect that knowledge to the practical reality of D-SNP enrollment and show you how these programs coordinate to benefit your clients.
Understanding this coordination is crucial because D-SNPs aren't just another Medicare Advantage plan—they're specifically designed to work with Medicare Savings Programs and Medicaid benefits to provide comprehensive, coordinated care for dual-eligible beneficiaries.
Most clients don't wake up one day eligible for D-SNPs. Instead, they follow a predictable path that you can help them navigate more effectively once you understand the sequence.
The journey typically begins when they become Medicare eligible, either by turning 65 or after receiving disability payments for 24 months. Often, particularly in the D-SNP population, this eligibility stems from a disability that has prevented them from working and left them relying on Social Security Disability Insurance (SSDI) income.
Once Medicare eligible, these individuals generally enroll in Parts A and B, often because they lack employer coverage to coordinate with their Medicare benefits. From there, they need to apply for a Medicare Savings Program through their state—this is where many clients get stuck without proper guidance. The application process can be confusing, and the distinction between different programs isn't always clear.
They also need to apply for the Low-Income Subsidy (Extra Help) through Social Security, though this sometimes happens automatically when they're approved for certain MSPs. Only after completing these steps do they become eligible for D-SNP enrollment, which is why understanding the underlying programs is so essential for agents working in this market.
With the MSP foundation in place, D-SNP eligibility becomes clearer. Full Benefit Dual Eligibles, QMB, QMB Plus, SLMB, and SLMB Plus beneficiaries all qualify for D-SNP enrollment. They must be enrolled in Medicare Parts A and B, be at least 21 years old for most plans, and live within the plan's service area.
One significant advantage when working with this population is that they can enroll in D-SNPs as soon as they become eligible for Medicaid, which grants them a Special Enrollment Period. This flexibility helps you serve clients whose circumstances change mid-year, unlike the rigid enrollment periods that govern most Medicare products.
Plans do limit enrollment to specific categories of dual eligibles, so understanding whether your client qualifies as a full or partial dual eligible determines which D-SNP options are available to them. Most D-SNPs focus on full dual eligibles because the coordination of benefits makes these plans particularly valuable for both their portfolio and your clients.
Explaining financial responsibility becomes easier when you understand how Medicare and Medicaid coordinate payments. For full dual eligibles, the process is straightforward: Medicare or the Medicare Advantage plan pays the primary portion (typically 80% for Part B services), and Medicaid pays the secondary portion (the remaining 20%). The beneficiary has no financial responsibility.
Consider a simple example: if a client's primary care physician has a contracted rate of $100 for a routine office visit, Medicare pays $80, Medicaid pays $20, and your client pays nothing. This isn't charity care—both payment sources work together to make the provider whole while protecting the beneficiary from out-of-pocket costs.
Even if your client is enrolled in a D-SNP PPO and goes out of network, they still have no financial responsibility. The plan pays its portion of the out-of-network coinsurance (say 50% or 70% depending on the plan), and Medicaid covers the balance. Be wary, though -- Medicaid benefits often do not function across state lines. This coordination makes D-SNP PPOs particularly attractive because they provide network flexibility without financial risk to the beneficiary.
For partial dual eligibles, the situation becomes more complex. These beneficiaries receive premium assistance through their MSP, but they remain responsible for copays and coinsurance since Medicaid isn't providing cost-sharing assistance. This is why understanding the difference between full and partial dual eligibles matters when recommending plans.
Understanding what happens when a beneficiary loses Medicaid mid-year is crucial for setting proper expectations. They receive a six-month grace period to be redetermined for eligibility, but their D-SNP coverage changes during that time.
The Medicare Advantage portion continues to function normally, but the Medicaid coordination pauses. This means the beneficiary becomes responsible for Medicare cost-sharing—copays, coinsurance, deductibles, and potentially premiums that were previously covered. If they remain ineligible for Medicaid after the six-month period, they'll be automatically disenrolled from the D-SNP.
However, this situation isn't hopeless. They receive Special Enrollment Periods both when they initially lose Medicaid eligibility and again if their D-SNP enrollment is terminated. This gives them opportunities to enroll in other Medicare Advantage plans or return to Original Medicare with a supplement, depending on their circumstances and budget.
D-SNPs offer several features that set them apart from regular Medicare Advantage plans, and understanding these differences helps you articulate their value to clients.
Prior authorization policies work differently in D-SNPs. Once a treatment or service receives approval, that authorization remains valid as long as the treatment is medically necessary. Your clients won't face annual reapproval hurdles for ongoing treatments like they might with traditional Medicare Advantage plans.
When clients switch between D-SNP plans—perhaps to access different benefits or change carriers—their existing prior authorizations remain valid for at least 90 days with the new plan. This continuity of care protection doesn't exist with regular Medicare Advantage plans and provides peace of mind during plan transitions.
D-SNPs also must meet federal care coordination requirements that go beyond typical Medicare Advantage obligations. They must coordinate with state Medicaid agencies, report hospital and skilled nursing facility admissions to the state, and facilitate Medicaid coverage appeals. This means that if a client faces a coverage denial, the D-SNP carrier becomes their first point of contact for appeals, even for Medicaid-related issues.
Most D-SNPs are designed to accommodate both full and partial dual eligibles, but they handle cost-sharing very differently for each population. Plans typically show cost-sharing ranges—for example, "$0 to $35" for premiums or "$0 to $30" for specialist visits.
For full dual eligibles, the cost-sharing is always at the lower end (often $0) because Medicaid picks up what the Medicare Advantage plan doesn't cover. For partial dual eligibles, the cost-sharing falls at the higher end because they're responsible for the portions that Medicaid would typically cover.
This design allows plans to serve both populations while using their rebate dollars efficiently. They can offer enhanced benefits knowing that full dual eligibles have their cost-sharing covered, while partial dual eligibles receive premium assistance through their MSP even if they have some out-of-pocket responsibilities.
Starting in 2026 in select Michigan counties, and statewide in 2027, new Highly Integrated Dual Eligible SNPs will launch as "MI Coordinated Health." These plans represent the evolution of D-SNP coordination by integrating long-term services and supports, including up to 180 days of nursing facility coverage annually.
This integration goes beyond current D-SNP capabilities and will provide even more comprehensive care coordination for dual-eligible beneficiaries. Some local and national carriers are preparing these enhanced products, which will offer seamless coordination between Medicare, Medicaid, and long-term care services.
Understanding how D-SNPs coordinate with Medicare Savings Programs and Medicaid benefits positions you to serve dual-eligible clients effectively. The payment coordination eliminates financial barriers that might prevent clients from accessing necessary care, while the enhanced coordination requirements ensure they receive comprehensive support.
In our final article in this series, we'll focus on the practical application of this knowledge: how to identify D-SNP candidates in your current book of business, effective prospecting strategies for the dual-eligible market, and how to help clients access the Medicare Savings Programs that make D-SNP enrollment possible.
The foundation is now in place—next, we'll put this knowledge to work building your dual-eligible business.