As the lock-in period kicks into gear, you’ve likely been hearing a lot about Dual Eligible Special Needs Plans (D-SNPs).
Whether you’re just getting started with D-SNPs or looking to refine your sales approach, this concise guide will provide you with all the essential information you need to understand these versatile and valuable plans.
What Are D-SNPs?
Dual Eligible Special Needs Plans (D-SNPs) are a specialized type of Medicare Advantage (MA) plan designed to meet the unique needs of individuals eligible for both Medicare and Medicaid.
The availability and benefits of D-SNPs are determined by each state, but they typically offer a range of valuable features, including:
- Care coordination services
- $0 monthly premiums
- Quarterly over-the-counter (OTC) allowances
- Comprehensive dental, vision, and hearing coverage
- Transportation assistance
- Access to gym memberships and wellness programs
These plans are tailored to provide extra support and benefits for dual-eligible individuals.
Understanding the Types of D-SNPs
D-SNPs can be categorized based on three key criteria: their network structure, the Medicaid eligibility levels they accommodate, and the degree of integration with Medicaid services.
PPO vs. HMO D-SNPs
When classified by network type, D-SNPs fall into two categories: Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans. The majority of D-SNPs are structured as HMOs, offering a more managed and cost-effective approach to care.
D-SNPs & Networks
| Types of D-SNP | Description | Who Should Apply |
| HMO |
· Beneficiaries must use in-network providers for all non-emergency healthcare services. · A primary care physician (PCP) is required, and referrals are needed to see specialists. · Generally associated with lower out-of-pocket (OOP) expenses. |
· Meets the eligibility criteria for a D-SNP.
· Prefers access to robust provider networks. · Comfortable with network limitations. · Prioritizes lower out-of-pocket expenses. |
| PPO | · Offers a network of providers but also covers services received outside the network.
· Beneficiaries usually incur higher costs when using out-of-network providers. · Generally does not require choosing a primary care physician or obtaining referrals to see specialists. |
· Eligible for a D-SNP.
· Prefers the flexibility of a broader provider network. · Open to slightly higher out-of-pocket costs when necessary. |
Full vs. Partial D-SNPs
D-SNPs can be categorized based on the level of Medicaid benefits they accommodate. These include Full-Benefit Dual Eligible (FBDE), Medicare Zero Cost Sharing, Dual Eligible Subset, and Dual Eligible Subset Medicare Zero Cost Sharing.
Partial D-SNPs, on the other hand, may enroll individuals who qualify under specific Medicaid categories, such as Medicare Zero Cost Sharing, Dual Eligible Subset, or Dual Eligible Subset Medicare Zero Cost Sharing. The eligibility criteria for enrollees vary depending on the specific plan.
D-SNPs & Medicaid Levels
| Type of D-SNP | Who Can Apply | Eligible Medicaid Categories |
| FBDE | · Dual-eligible individuals who qualify for full Medicaid benefits during any part of a given month under any eligibility category or receive medical assistance for any portion of the month.
· Must be enrolled in or actively in the process of enrolling in a Medicaid Managed Care Organization (MMCO). |
· FBDE · QMB+ · SLMB+ |
| Medicare Zero Cost Sharing | · Dual-eligible individuals who are exempt from cost-sharing responsibilities for Medicare Parts A and B. |
· QMB · QMB+ |
| Dual Eligible Subset | · Individuals belonging to specific dual-eligible groups identified through a carrier’s collaboration with a State Medicaid Agency. |
· FBDE · QMB · QMB+ · SLMB · SLMB+ · QI · QDWI |
| Dual Eligible Subset Medicare Zero Cost Sharing | · Individuals from specific dual-eligible groups, identified through a carrier’s coordination with a State Medicaid Agency, who are exempt from Medicare cost-sharing. |
· FBDE · QMB · QMB+ · SLMB · SLMB+ · QI · QDWI |
Starting January 1, 2027, parent organizations with an affiliated Medicaid plan in a specific region will be limited to offering a single Full-Benefit Dual Eligible (FBDE) D-SNP in that area. However, they may still offer additional D-SNPs for partial dual-eligible individuals within the same region.
Integrated vs. Non-Integrated D-SNPs
D-SNPs vary in the extent to which they coordinate with their state’s Medicaid program. Fully integrated D-SNPs (the highest level of integration) are managed by a single entity that holds both a Medicare Advantage (MA) contract with CMS and a Medicaid Managed Care Organization (MMCO) contract with the state.
Highly integrated D-SNPs coordinate with their state’s MMCO through one of the following:
- The same Medicare Advantage organization,
- The parent organization of the MA plan, or
- Another entity owned and controlled by the parent organization.
Integration enhances alignment, allowing enrollees to receive both their Medicaid and Medicare benefits through the D-SNP or its affiliated MMCO.
Non-integrated D-SNPs, on the other hand, are not connected to their state’s MMCO.
Certain D-SNPs offer exclusively aligned enrollment, meaning they only accept individuals who receive Medicaid benefits through the D-SNP or its affiliated MMCO. These plans cannot enroll partial dual-eligible individuals, as they are not enrolled in an MMCO.
There are four types of integrated D-SNPs, outlined below.
D-SNPs & Medicaid Integration
| Type of Integrated D-SNP | Description | Example |
| Fully Integrated (FIDE-SNPs) | · Fully Integrated D-SNP (FIDE-SNP): The most integrated type of D-SNP.
· Operated by a single entity with capitated contracts to deliver both Medicare and Medicaid services. · Medicaid contracts encompass nearly all Medicaid benefits, including long-term services and supports (LTSS). · All FIDE-SNPs will transition to Aligned Integration Plans (AIPs) by plan year 2025. |
· ABC Health FIDE-SNP delivers comprehensive coverage by offering both Medicare and Medicaid services. |
| Highly Integrated (HIDE-SNPs) | · Operate under Medicare and Medicaid contracts, either directly or through separate entities within the same parent organization.
· Medicaid contracts must include most Medicaid services, such as long-term services and supports (LTSS) or behavioral health, though they are not required to cover both. · May qualify as an Aligned Integration Plan (AIP). |
· XYZ Health HIDE-SNP covers all Medicare services, while XYZ Health MMCO provides the majority of Medicaid services. |
| Coordination-Only (CO D-SNPs) | · Least Integrated D-SNP: Features minimal integration with Medicaid services.
· Coordination requirements with Medicaid are broadly defined and less specific. · Must notify the state when a member is admitted to a hospital or skilled nursing facility. |
· YES Health CO D-SNP offers limited care coordination in partnership with 123 Health MMCO. Beneficiaries receive both a YES Health card and a 123 Health MMCO card. |
| Applicable Integrated Plans (AIPs) | · Offers Exclusively Aligned Enrollment
· Applicable to FIDE-SNPs, HIDE-SNPs, or Coordinated-Only D-SNPs. · Exclusively available to individuals who qualify as full-benefit dual-eligible. |
· Possibly transitioning to ABC Health FIDE-SNP (fully integrated under ABC Health by Plan Year 2025).
· Potentially offered as XYZ Health HIDE-SNP. · May also be available as YES Health CO D-SNP. |
Who Is Eligible for D-SNPs?
Dual-eligible individuals—those of any age who qualify for both Medicare and Medicaid—are eligible for D-SNPs.
- Medicare Eligibility: Individuals must be 65 or older or have a qualifying disability.
- Medicaid Eligibility: Eligibility is based on income and asset levels, which must fall below thresholds set by their state.
The type of D-SNP a dual-eligible individual can enroll in depends on their Medicaid eligibility category (refer to the D-SNP & Medicaid Levels table) and the plans available in their service area.
It’s crucial to verify a client’s Medicaid eligibility before enrolling them in a D-SNP. Many D-SNP carriers provide agent support to assist with this process.
Upcoming Changes:
- Starting in 2027, only full-benefit dual-eligible individuals enrolled in (or in the process of enrolling in) a D-SNP’s affiliated Medicaid plan will be eligible for those plans.
- By 2030, D-SNPs with an affiliated Medicaid plan must disenroll any dual-eligible members who are not also enrolled in the affiliated Medicaid plan.
Default Enrollment
Individuals may be automatically enrolled in a D-SNP if they are Medicaid beneficiaries who become newly eligible for Medicare and are enrolled in a Medicaid MMCO affiliated with the D-SNP.
Before the enrollment takes place, individuals must be notified at least 60 days in advance and provided the option to opt out of the enrollment.
When Can You Sell D-SNPs?
D-SNPs can be sold under the same enrollment periods as other Medicare Advantage (MA) plans, including:
- Initial Coverage Election Period (ICEP)
- Annual Enrollment Period (AEP)
- Medicare Advantage Open Enrollment Period (MA OEP)
If someone qualifies for an integrated D-SNP, they become eligible for a Special Enrollment Period (SEP) to join the plan. Additionally, as long as they remain eligible for both Medicare and Medicaid, they can use an SEP to elect an integrated D-SNP once per month.
D-SNP Election Periods
| D-SNP Election Period | What’s Permitted for Contract Year 2024 | What’s Permitted for Contract Year 2025 |
| ICEP | One change is allowed during the three months before enrolling in Medicare Parts A and B, up to either:
· The last day of the month prior to enrollment in Parts A and B, or · The final day of the Part B Initial Enrollment Period, whichever comes later. |
One change allowed during the three months before enrolling in Medicare Parts A and B, up to either:
· The last day of the month before enrollment in Parts A and B, or · The final day of the Part B Initial Enrollment Period, whichever comes later.* |
| AEP | One change allowed during the period from October 15 to December 7. | One change permitted during the period from October 15 to December 7.* |
| Switching during MA OEP | One change permitted between January 1 and March 31. | One change allowed between January 1 and March 31.* |
| SEP for electing a FIDE-SNP, HIDE-SNP, or AIP as eligible, mid-year | One change allowed per quarter, excluding the final quarter of the year. | One change per month is allowed for full-benefit dual eligible, solely to support aligned enrollment. |
| SEP for electing a non-integrated D-SNP as eligible, mid-year | One change permitted each quarter, except during the fourth quarter. | No longer exists |
*Exception: Full-benefit dual-eligible individuals enrolled in Medicaid MCOs cannot choose misaligned D-SNPs where applicable.
Where Can You Find D-SNP Prospects?
D-SNP prospects are abundant, particularly if you operate in urban or low-income areas. However, attracting prospects may be more challenging if you work near rural regions with limited healthcare providers (since CMS restricts D-SNPs in such areas) or in moderately to highly affluent areas where dual-eligible individuals are less likely to reside.
Timing Matters:
Dual-eligibles often manage their finances around welfare and Social Security payments, which are disbursed early in the month. This creates opportunities to engage prospects at specific locations:
- First Half of the Month: Visit places where dual-eligibles shop or spend money.
- Second Half of the Month: Focus on locations where they seek assistance.
While you cannot directly scout potential clients, you can host compliant Medicare educational or sales events or distribute compliant promotional materials in areas frequented by D-SNP prospects. This approach positions you as a trusted resource in the community and encourages prospects to approach you.
Suggested Locations to Find D-SNP Prospects
First Half of the Month (Shopping Locations):
- Dollar stores (e.g., Dollar Tree, Dollar General, Family Dollar)
- Discount retailers (e.g., Walmart, Ollie’s Bargain Outlet, Price Rite, Big Lots, Ocean State Job Lot)
- Thrift shops and flea markets
Second Half of the Month (Assistance Locations):
- Food pantries
- Food banks
- Soup kitchens
Anytime Throughout the Month:
- Utility assistance centers
- Community events (e.g., senior expos, health fairs)
- Charity events
- Churches or other faith-based organizations
- Areas with low-income housing
- Senior centers
- Retirement communities
How to Grow Your D-SNP Business
Building a successful D-SNP book of business requires focusing on two key strategies: leveraging grassroots marketing and delivering exceptional customer service.
Grassroots Marketing: Your Path to D-SNP Leads
Grassroots marketing is one of the most effective ways to connect with potential D-SNP clients and grow your client base. This approach involves immersing yourself in the community, engaging directly with prospects, and fostering relationships with professionals who can refer clients to you.
Here are some grassroots marketing strategies to consider:
- Volunteer in the Community: Spend time at food banks, food pantries, soup kitchens, and charity events to connect with prospects.
- Visit Key Locations: Engage with individuals at community centers, retirement communities, and areas with low-income housing.
- Distribute Marketing Materials: Hang tear-off flyers or leave business cards on bulletin boards at indoor flea markets, thrift stores, or churches.
- Build Partnerships: Collaborate with churches, provider offices, non-profit organizations, and retailers to create referral networks.
- Host a Booth: Set up your own booth at community events to increase visibility and build trust.
- Organize Educational and Sales Events: Host Medicare educational or sales events to inform prospects and position yourself as a resource for their needs.
By embedding yourself in the community and maintaining a helpful, approachable presence, you can establish trust and credibility while generating a steady flow of D-SNP leads.
“Establish yourself as a trusted resource in the community, and clients will naturally seek you out.” – Essential Care
Note: It is essential to adhere to all CMS Medicare Advantage and Part D Communication Requirements when marketing these plans or hosting events. For detailed guidance on maintaining compliance, refer to our Medicare compliance do’s and don’ts.
Delivering Outstanding Customer Service
Providing exceptional customer service is key to turning prospects into clients, earning referrals from existing clients and community professionals, and ensuring long-term client retention.
Here’s how you can stand out by offering superior service:
- Stay Knowledgeable: Be well-versed in the topics your prospects and clients frequently ask about, so you can address their questions with confidence.
- Educate Your Clients: Help prospects and clients understand their health insurance options and programs, empowering them to make informed decisions.
- Clarify Benefits and Access: Ensure your clients fully understand their plans, benefits, and how to access the care they need.
- Provide Additional Support: When appropriate, connect prospects or clients with other resources, programs, or professionals who can assist with non-health insurance-related needs.
Treating your clients with care and expertise not only strengthens your relationships but also establishes you as a trusted resource in your community.
How to Retain D-SNP Clients
The ability for dual-eligible individuals to join or switch D-SNPs at any time during the year is a double-edged sword. While it allows you to find new Medicare Advantage clients year-round, it also gives other agents the chance to win over your existing clients.
To retain your D-SNP clients, consider these strategies:
- Build Trust: Establish yourself as a reliable resource for their health insurance questions and concerns. Let them know they can count on you.
- Provide Exceptional Customer Service: Go the extra mile to assist them while maintaining a professional relationship. Communicate clearly, both in person and through digital channels.
- Ensure Accessibility: Make it easy for clients to reach you when needed. Share your phone number and email address. Pro Tip: Fridge magnets are less likely to be misplaced than business cards!
- Follow Up Regularly: Check in with clients within the first 30 and 90 days, then every six months to a year. Ask how they’re doing, if their income or prescription drug needs have changed, and whether they’ve utilized extra benefits like dental, vision, or over-the-counter allowances.
By taking these steps, you can build lasting client loyalty. Remember, even small gestures can have a significant impact on your clients’ satisfaction and trust.
Why Sell D-SNPs?
Selling D-SNPs can provide a steady stream of commissions during Medicare’s off-season, but there’s an important caveat: if your sole motivation is profit, you may quickly realize this market isn’t the right fit for you.
Working with the dual-eligible population often comes with challenges. Many individuals are confused about their health insurance options, and you’ll need to clearly and patiently explain their choices while answering questions effectively. It’s a role that requires compassion, adaptability, and strong communication skills. Additionally, you may find yourself in situations or environments that feel outside your comfort zone.
Agents who excel in selling D-SNPs do so because they genuinely care about helping others and making a difference in their clients’ lives. If your goal is to serve your community while growing your business, D-SNPs may be the perfect fit for you.
Not affiliated with or endorsed by Medicare or any government agency.
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