D-SNP Plan Options in New Mexico

Medicare offers health insurance coverage to people over the age of 65. Medicaid, on the other hand, provides health insurance care coverage for those under 65 who qualify due to a disability. Medicare is a federally funded and managed program, while Medicaid is administered at the state level. Medicaid can also provide benefits to qualified low-income residents, but the requirements can vary from state to state.

The Basics of D-SNP

Some individuals qualify for both Medicare and Medicaid coverage. Dual Eligible Special Needs Plans (D-SNPs) are a particular type of Medicare Advantage plan created for those enrollees who are entitled to both Medicare and Medicaid benefits. A D-SNP combines Medicare and Medicaid benefits, and limits enrollment to only those who qualify.

Enrollment in D-SNPs is available to all categories of individuals who are eligible for Medicaid. There are further restrictions within each of these categories. Certain conditions must be met to qualify for enrollment in a D-SNP.

Dual eligible enrollees meet the following criteria:

  • Meet eligibility requirements for both Medicare and Medicaid and are enrolled in both programs
  • Over the age of 65 or under 65 with a qualifying disability
  • Have health care concerns that may be more costly than typical

Fully Integrated Dual Eligible SNPs

To fully integrate and coordinate Medicare, Medicaid and it’s benefits for dual eligible beneficiaries, Congress created the Fully Integrated Dual Eligible SNP as part of the Affordable Care Act. The purpose of the legislation is to promote the coordination and integration of dual eligible benefits and beneficiaries under a single managed care organization.

To do so, fully integrated dual eligible SNPs must meet the following criteria:

  • There must be a specialized Medicare Advantage plan made for dual eligible special needs individuals
  • Be operating during the next contract year
  • They must have been in operation during the entire previous calendar year
  • They must facilitate access to Medicare and Medicaid benefits as covered in the state’s Medicare plan
  • Have a contract with the state’s Medicaid agency that includes coverage for specific benefits including acute, primary and long-term benefits. The capitated coverage must be in line with the state’s policy
  • They must coordinate the delivery of both Medicare and Medicaid health and long-term care services and benefits. To do so, they should use care management and specialty care networks and methods aligned for high-risk beneficiaries.
  • Adapt and promote policies and procedures that are approved by CMS and the state to both coordinate and integrate member materials and communications, enrollments, grievance process, appeals processes and proves and quality improvement channels.

If you are a dual eligible enrollee and have questions about your coverage, contact us.