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Duel Eligible – Special Needs Plans (D-SNP) are not available only for special needs planning for disabled people.  It is the fastest growing component of health insurance for concurrently eligible insureds having both Title 2 and Title 16 eligibility which triggers Medicare and Medicaid health insurance.  The term “Special Needs Plans” refers not to the disability or “special needs” of the insured, but to the requirement in the 2010 Affordable Care Act for CMS to seek maximum coordination between Medicare and Medicaid for individuals insured by both programs simultaneously.  

Private insurance companies spend huge television budgets to attract individuals to their Medicare Advantage plans.  Approximately 49% of Medicare beneficiaries elect Medicare Advantage plans.  

Recent history.  In Florida there are over 180,000 people whose Title 2 retirement or SSDI check was less than the SSI Federal Benefit Rate, thus entitling the person to receive two checks each month, the Title 2 check plus the Title 16 Supplemental Security Income check.  Receipt of each check triggers two separate health insurance programs.  Experience had shown that having two separate insurance plans – one for Medicare and one for Medicaid – often led to missed opportunities to provide the best care due to lack of coordination between them. 

Florida ’s Agency for Health Care Administration (AHCA)response was to accept the CMS invitation to require Medicare Advantage plans seeking additional insureds was to require that they cannot solicit individuals who also had Medicaid into their D-SNP plans unless the private insurance company also became a Florida Medicaid Managed Care insurer. This resulted in Florida becoming one of the earliest adopters of CMS’s Fully Integrated Duel Eligibility (FIDE SNP) plan in 2022.  For example, Aetna insurance, a major player in the Medicare Advantage world, was advised by Florida AHCA that they could not recruit duel eligible insureds unless Aetna also became a Florida Medicaid Managed Care organization. 

Low-income individuals eligible for Medicare Savings Programs for example QMB, are designated as potential duel eligible individuals who can join a FIDE Duel Eligible Special Needs Plan.  In addition, the state can opt to buy-in certain high use Medicaid insureds into Medicare for the cost of the Medicare premium.

What benefit does the State of Florida receive from promoting D-SNP?  The answer lies in its funding responsibilities.

Medicare Advantage plans are funded 100% by payment by the federal government at approximately $950 per month to the private Medicare Advantage insurance companies who agree to provide in Medicare Part C all the services to the insureds that the insureds would receive if they maintained their Medicare Parts A and B. 

Medicare is primary insurance while Medicaid is the payor of last resort.  

Medicaid potentially requires the State of Florida to pay up to a maximum of 50% of the insureds’ claims under the federal/state joint Federal Medical Assistance Percentage (FMAP) for Medicaid.  Florida, being relatively poorer than the majority of states, is currently under a 57% federal, 43% state split. Before Medicaid Managed Care, the fee-for-services costs could be astronomical to the state, as was the Medicaid lien at death of the SNT beneficiary.

By encouraging maximum participation in Medicare Advantage, and with Medicare being primary, the state’s financial responsibility shifts dramatically in its favor.  

Under the D-SNP program, the federal government pays the Medicare Part C insurance company, and the state pays a much smaller additional premium of approximately $200 per month to the same insurance company to provide Medicaid services.  The state’s contribution each month then does NOT depend on the patient’s actual medical expenses at all.  The private insurance company provides all the mandatory Medicare and Medicaid services needed by the individual. The state’s total outlay is $200 per month per patient.

The result is shifting the responsibility for some insureds from 43% Medicaid where the state pays a portion of primary care, to Medicare where the state pays nothing.  The state’s obligation is a maximum of $200 per month to assure 100% coverage for hospitalization, physicians, labs, prescription costs (with no hole in the donut issues), and related services.

What is the advantage of D-SNP for SNT beneficiaries? The answer lies in the expected Medicaid lien at death, an important consideration by some clients before they agree to put excess resources/assets into an individual Special Needs Trust.

Before Medicaid Managed Care, neither beneficiaries nor their attorneys had no idea what the client’s Medicaid lien would be at death. If the insured now becomes a member of a D-SNP plan, the attorney can advise the client that the lien at death is repayment to Florida of the $200 monthly premium from the date of funding the d4A SNT until their death.  It is not the repayment of the medical services used at all.

How does the attorney apply for D-SNP?  The attorney doesn’t! Google D-SNP in your county. Competent clients can contact the various private insurers offering D-SNP plans.  The insurance company staff do the applications and assure coverage for those eligible.  If the client wants to compare various insurance company plans in any county, but doesn’t want to contact them individually, contact an independent insurance broker.

D-SNP insurers offer everything that Medicaid does, plus often extra dental, vision and hearing benefits, other features such as transportation, over the counter medications, and a personal care team. The personal care team for Aetna, for example, consists of a care coordinator, a nurse care manager, a member advocate and a social worker. Clients report that the social workers are quite aggressive about making the client get up to date vaccinations, lab tests for diabetes, and annual checkups.  That’s the secret to keeping insurance costs down – early identification and treatment while problems are small.