The dual-eligible special needs plan (D-SNP) market represents an untapped opportunity for independent health insurance agents. With 17-20% of Medicare-eligible consumers also qualifying for Medicaid, understanding Medicare Savings Programs (MSPs) is crucial for identifying potential D-SNP candidates and serving this population effectively.
Yet many agents remain nervous about this market, unsure of how these programs work behind the scenes. We get it—the vocabulary alone is overwhelming, and now you're stuck at the intersection of two government programs.
This three-part series will shed light on Medicare Savings Programs and help you leverage this knowledge to identify and serve dual-eligible clients. In this first installment, we'll establish the foundation you need to understand MSP eligibility, benefits, and common complications.
Before diving into specific programs, let's address a critical distinction that creates confusion even among experienced agents: Medicare Savings Programs are not Medicaid programs, despite being administered by state Medicaid agencies.
This means you can have clients who qualify for an MSP without being enrolled in Medicaid. In Michigan, the Department of Health and Human Services administers MSP benefits, but the qualification criteria and benefits differ from traditional Medicaid programs. Similarly, Part D's Extra Help program operates as a Medicare program, not a Medicaid program, though beneficiaries often qualify for both simultaneously.
Understanding this distinction becomes crucial when explaining to clients why they might qualify for certain benefits but not others, and why their Medicare Savings Program might continue even if their Medicaid status changes.
All Medicare Savings Programs require both income and asset testing, and understanding what counts toward these limits helps you quickly assess whether a client might qualify. The government essentially looks at anything liquid or near-liquid that could help pay for healthcare costs. This includes obvious items like checking and savings accounts, retirement accounts, and any stock or bond holdings the client might have. Monthly income from all sources factors into the calculation as well.
However, recognizing what doesn't count is equally important for qualifying clients. In Michigan, the primary residence doesn't count toward asset limits, nor does one vehicle, one burial plot, or up to $1,500 in burial expenses. The government also disregards furniture and household items—they're not going to evaluate whether your client owns a blender. The focus remains on assets that could realistically be converted to pay for healthcare.
Keep in mind that other states may treat these exclusions differently. So if you work across state lines, you'll need to verify the specific rules for each state. In any case, the state Medicaid agency is the final arbiter of who qualifies for any of these programs.
While not technically a Medicare Savings Program, Full Benefit Dual Eligibles (FBDEs) represent a significant portion of D-SNP eligible clients you'll encounter. These beneficiaries typically receive SSI as their primary income source and maintain resources under $2,000 for singles or $3,000 for couples.
FBDEs are good D-SNP candidates for a variety of reasons. They have no Part A premium responsibility, receive Part B premium assistance in Michigan, enjoy cost-share protection for Medicare services, and receive full Medicaid benefits. This combination makes D-SNPs an attractive option, since enrollees will face little-to-no financial responsibility for their premiums or healthcare.
The QMB program serves beneficiaries with incomes under 100% of the Federal Poverty Level—currently $1,325 monthly for singles or $1,783 for couples in 2025. Resource limits are set at $9,660 for singles and $14,470 for couples.
QMB beneficiaries receive the most comprehensive Medicare Savings Program benefits available. The program covers Part A and B premiums, deductibles, coinsurance, and copayments. Importantly, coverage begins from the application approval date with no retroactive coverage, so timing matters when helping clients apply.
One significant protection for QMB beneficiaries is that providers cannot balance bill them for Medicare-covered services. They also automatically qualify for Extra Help, though you should verify this enrollment since automation doesn't always work as intended.
QMB Plus beneficiaries meet the same income and asset criteria but also qualify for full Medicaid benefits in their state. Often, they achieve this through Michigan's spend-down program, which creates important considerations we'll discuss shortly.
The SLMB program targets beneficiaries whose incomes fall between 100-120% of the Federal Poverty Level—essentially those who earn too much for QMB but still need assistance with Medicare costs. For 2025, this means singles earning $1,325.01 to $1,590 monthly, or couples earning $1,783.01 to $2,135 monthly.
Unlike QMB, SLMB focuses specifically on Part B premium assistance, but it offers some retroactive benefits by covering up to three months of previous premiums. The program also covers all future months where the beneficiary's income remains within the qualifying range. Like QMB beneficiaries, SLMB participants automatically qualify for Extra Help, though verification remains important.
SLMB Plus beneficiaries receive the same Part B premium assistance but also qualify for full Medicaid benefits, often through the spend-down process.
Understanding the "Plus" designation is straightforward: it simply means the beneficiary also qualifies for full Medicaid benefits in their state, providing additional assistance beyond the Medicare Savings Program benefits. This additional coverage makes these beneficiaries particularly well-suited for D-SNPs, since the plans can coordinate both Medicare and Medicaid benefits.
Understanding spend-downs becomes crucial when working with MSP Plus beneficiaries, though the concept often confuses both agents and clients. Think of a spend-down as a deductible that beneficiaries must meet before their Medicaid benefits activate. In Michigan, this resets monthly—beneficiaries must satisfy their spend-down amount each month before Medicaid kicks in for the remainder of that month.
Here's where things get complicated: beneficiaries with both Extra Help and spend-down requirements face a significant challenge. Since Extra Help limits prescription costs to no more than $12.15 per fill, beneficiaries may struggle to meet their monthly spend-down amount through prescription expenses alone. This creates a paradox where two beneficial programs work against each other—the Extra Help keeps prescription costs low, but those low costs prevent the beneficiary from meeting their spend-down to access other Medicaid benefits.
Being transparent about this issue builds trust with clients and helps them understand why their benefits might not work as expected. There aren't many solutions to this problem, but clients appreciate honesty about the limitations they might face.
Two additional programs serve smaller populations but are worth understanding. The Qualifying Individual program helps beneficiaries earning between 120-135% of the Federal Poverty Level with Part B premiums only. Unlike other MSPs, QI requires yearly renewal and operates on a first-come, first-served basis, with preference given to previous year participants.
The Qualified Disabled Working Individual program serves a very specific population: disabled beneficiaries who returned to work and lost their premium-free Part A as a result. For beneficiaries earning up to 200% of the Federal Poverty Level, QDWI helps cover Part A premiums they now owe due to their return to work.
Most D-SNPs don't include QI and QDWI beneficiaries in their eligibility criteria since these programs only provide premium assistance without the cost-sharing protection that makes D-SNPs valuable to their portfolios.
Understanding these Medicare Savings Programs creates the foundation for success in the D-SNP market. Each program serves specific income brackets and provides different levels of assistance, but they all open doors to D-SNP eligibility for your clients.
In our next article, we'll explore how D-SNP enrollment works with these MSPs, how Medicare and Medicaid coordinate payments, and what makes D-SNPs different from traditional Medicare Advantage plans. This knowledge will help you share the value proposition with your dual-eligible clients and understand when D-SNPs make the most sense.
The key takeaway from this foundation: Medicare Savings Programs are more accessible than many clients realize, and they provide the gateway to D-SNP benefits that can significantly improve healthcare affordability and coordination for your most vulnerable clients.