Understanding Special Needs Plans
Laying a Solid Foundation | Lesson 3

D-SNP Eligibility

The best place to begin talking about D-SNPs is eligibility.

We’ll answer the question, “who is able to join a Dual Eligible Special Needs Plan?”

Since these are still Medicare Advantage plans, they must meet the basic requirements for those plans, like being enrolled in Medicare Part A and Part B and living in the plan’s service area.

In addition, they must also be entitled to their State’s Medicaid program to be eligible for a D-SNP.

Medicaid Eligibility is broken down into five different eligibility categories. These are sometimes also referred to as the Medicare Savings Program.

Medicaid covers different Medicare costs depending on the eligibility category, so let’s work through those here.

The first category is the Qualified Medicare Beneficiary or QMB. This category can be further broken down into QMB Only and QMB Plus. These individuals have income up to 100 percent of the Federal Poverty Level. Beneficiaries in this category will have their Part A premium and Part B premiums covered, and some or all of their Part A and Part B costs like deductibles, copays, and coinsurance covered by Medicaid. The only difference between QMB Only and QMB Plus is that QMB Plus beneficiaries also qualify for full Medicaid benefits with their state.

The next category is the Specified Low-Income Medicare Beneficiary or SLMB. Like the QMB, this also can be broken down into SLMB Only and SLMB Plus, with SLMB Plus beneficiaries having access to full Medicaid benefits through their state. Beneficiaries in this category have income between 100 percent and 120 percent of the Federal Poverty Level and will have their Part B premiums covered by Medicaid. In addition to the Part B premium, SLMB Plus beneficiaries may have certain cost-sharing items covered for their Part A and Part B services, depending on their state’s Medicaid coverage.

The third eligibility category is Qualified Individuals, abbreviated as QIs. Qualified individuals have income between 120 percent and 135 percent of the federal poverty level, and they will receive coverage for the Part B premium if their state’s Medicaid program has the funding available.

Next up, Qualified Disabled and Working Individuals or QDWIs. These individuals were eligible for premium-free Part A since they qualified for Social Security disability insurance but lost their premium-free Part A because they returned to work. Individuals in this category have income under 200 percent of the federal poverty level and will have their Part A premiums covered by Medicaid.

The fifth and final category is Full-Benefit Medicaid only. As you may have guessed, these individuals qualify for full Medicaid benefits with their state but are not eligible for the QMB or SLMB categories. Because Medicaid benefits can vary state by state, coverage for the part B premium and Parts A and B cost sharing will vary from state to state.

Although these categories give the beneficiary some extra coverage for their Original Medicare payments, they may not all allow someone to join a D-SNP in their area. D-SNPs may accept dual-eligible beneficiaries from all categories, or just select categories. It is common to see D-SNPs accepting QMB, QMB Plus, SLMB Plus, and Full Benefit dual-eligible categories, but there are some that will accept any eligibility category.

With all of these acronyms and separate benefits, it can seem a bit overwhelming when getting started. However, it doesn’t have to be. If you can narrow down your sales territory you can leverage carrier resources to help you thrive in this market.

Each D-SNP will outline what eligibility categories are accepted in the plan’s summary of benefits.

In addition to this, they will also have a service team or tool that will allow an agent to verify their client’s eligibility for the plan prior to enrolling. Since it might not be the most tactful to ask, “How much money do you make?” you can ask some basic fact-finding questions to identify if your client may be eligible for a Dual Eligible Special Needs Plan. For example, you could ask “what insurance cards do you use when you go to the doctor?” If they show you a state Medicaid card, you could take that next step and contact the carrier to verify their eligibility in the plan.

Now that you know who qualifies, let’s talk about enrolling these clients into a benefit-rich plan!

Mentioned in this Lesson:

Medicare Savings Program Breakdown

Watch the Next Lesson