Dual Eligible Special Needs Plans (D-SNPs) enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the individual’s eligibility.
Medicaid Eligibility Categories
The Medicaid eligibility categories encompass all categories of Medicaid eligibility including:
- Full Medicaid (only): Individuals who qualify for complete Medicaid benefits.
- Qualified Medicare Beneficiary without other Medicaid (QMB Only): Medicare beneficiaries with income at or below 100% of the Federal Poverty Level. Medicaid pays Medicare Part A and B premiums, deductibles, coinsurance, and copayments.
- QMB Plus: Individuals who receive both QMB benefits and full Medicaid benefits.
- Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB Only): Medicare beneficiaries with income above 100% but below 120% of the Federal Poverty Level. Medicaid pays Medicare Part B premiums only.
- SLMB Plus: Individuals who receive both SLMB benefits and full Medicaid benefits.
- Qualifying Individual (QI): Medicare beneficiaries with income between 120% and 135% of the Federal Poverty Level. Medicaid pays Medicare Part B premiums only. QI is only available for people who don’t qualify for any other Medicaid coverage or benefits.
- Qualified Disabled and Working Individual (QDWI): Individuals who lost Medicare Part A coverage when they returned to work but can buy back these benefits and have an income up to 200% of the Federal Poverty Level. Medicaid pays Medicare Part A premiums.
States may vary in determining their eligibility categories; therefore, there may be state-specific differences in the eligibility levels in comparison to those listed here. For specific information regarding Medicaid eligibility categories, refer to the Medicaid website.
2025 Updates for D-SNPs
D-SNPs continue to evolve with important changes taking effect in 2025:
- Expanded Enrollment Options: Starting in 2025, full-benefit dually eligible individuals will have access to a monthly integrated Care Special Enrollment Period (SEP). This allows them to enroll in a fully integrated Dual Eligible Special Needs Plan (FIDE-SNP), a highly integrated Dual Eligible Special Needs Plan (HIDE-SNP), or an Applicable Integrated Plan (AIP) on a monthly basis.
- Enhanced Benefits: Many D-SNPs are expanding their supplemental benefits, including allowances for food, utilities, and other health-related needs. Some plans will include allowance rollover features, letting members carry unused benefits from one month to the next.
- Prescription Drug Costs: For those qualifying for Extra Help, the maximum copayment for covered prescription drugs in 2025 is $12.15.
- Improved Coordination: D-SNPs are implementing stronger coordination between Medicare and Medicaid benefits to streamline care delivery and reduce fragmentation.
Types of D-SNPs
There are several models for integrating Medicare and Medicaid services:
- Standard D-SNPs: Coordinate benefits across Medicare and Medicaid with varying levels of integration.
- Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP): Fully integrate care for dually eligible beneficiaries under a single managed care organization, covering primary, acute, and long-term services and supports.
- Highly Integrated Dual Eligible Special Needs Plan (HIDE SNP): Offer a higher level of integration than typical D-SNPs, including coverage of long-term services and supports, behavioral health, or both.
- D-SNP Affiliated with Managed Long-Term Services and Supports (MLTSS): Align with state MLTSS programs to provide comprehensive coverage for those needing long-term care.
NOTE: CMS no longer categorizes D-SNPs by subtype (see the December 7, 2015, HPMS memo “Discontinuation of Dual Eligible Special Needs Plans Sub-type Categories”).
Enrollment Considerations
When considering enrollment in a D-SNP, individuals should:
- Confirm their Medicaid eligibility category, as this determines which D-SNP they can join
- Check with their state’s Medicaid office about specific eligibility requirements and available D-SNP options
- Review whether their current healthcare providers are in the D-SNP’s network
- Understand how the D-SNP coordinates with their specific Medicaid benefits
- Consider additional benefits offered by various D-SNP plans that may address their unique needs
