Are you having trouble selling to your clients due to their low budgets? Some of your clients may be eligible for a combination of Medicare and Medicaid known as a D-SNP.
Special Needs Plans, or SNPs, are reserved for those with special medical needs or chronic illnesses. They are also available for those living in a skilled care facility. D-SNPs, or Dual-Eligible Special Needs Plans, are for SNP beneficiaries who are eligible for both Medicare and Medicaid and receive benefits from both.
We’ve simplified the CMS guidelines for eligibility below.
CMS separates D-SNP eligibility into the following categories:
- QMB (Qualified Medicare Beneficiary) – Income of 100% FPL (Federal Poverty Level) or less and resources no more than twice the SSI (Social Security Income) limit; Not otherwise eligible for Medicaid. Medicaid pays Original Medicare costs.
- QMB+ – Meet standards for QMB and is eligible for full Medicaid benefits. Medicaid pays Original Medicare costs.
- SLMB (Specified Low-Income Medicare Beneficiary) – Income between 100-120% FPL and resources no more than twice the SSI limit; Not otherwise eligible for Medicaid. Medicaid pays for Medicare Part B only.
- SLMB+ – Meets standards for SLMB and full Medicaid benefits. Medicaid pays for Medicare Part B only.
- QI (Qualifying Individual) – Income between 120-135% FPL and resources no more than twice the SSI limit; Not otherwise eligible for Medicaid. Medicaid pays for Medicare Part A only.
- QDWI (Qualifying Disabled and Working Individual) – Lost Medicare Part A after returning to work, but is eligible to re-enroll. Income below 200% FPL and resources no more than twice the SSI limit; Not eligible for Medicaid. Medicaid pays for Medicare Part A only.
- FBDE (Other Full Benefit Dual Eligible) – Does not meet QMB or SLMB but is eligible for Medicaid.
There are four types of D-SNPs:
- All-Dual – For beneficiaries eligible for Medicare Advantage and Medicaid.
- Full-Benefit – For beneficiaries eligible for full Medicaid.
- Medicare Zero Cost Sharing – For QMB and QMB+ eligible clients only. Can include cost sharing.
- Dual Eligible Subset – Can include cost sharing.
Fully Integrated Dual Eligible SNPs
Much like ACOs (Affordable Care Organizations), FIDE SNPs were created under the ACA to provide Medicare and Medicaid coordination under one organization. FIDE SNPs are specifically designed to provide all care for dual eligible beneficiaries. Organizations who want to be a FIDE SNP must have an approved CMS contract through their state Medicaid office. They must follow strict guidelines that CMS sets which aid with enrollment, communications, and grievance and appeals.
Although it is always important to place care and coverage above finances, make sure your clients are exposing their true financial capabilities so that you can help them determine if they are eligible for D-SNPS.