If you’re only selling Medicare Advantage plans to T65s, you may be missing out on millions of potential clients.
A Dual-Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage (MA) special needs plan available to beneficiaries enrolled in both Medicare and Medicaid. A D-SNP combines coverages and helps coordinate Medicare and Medicaid benefits for beneficiaries. The individual states decide which D-SNP plans carriers can offer and may review the specific benefits provided.
Dual-eligible people fall into several Medicaid eligibility categories. This will determine the type of D-SNP plan you can enroll a beneficiary in, their access to Medicaid benefits, and the level of help they can receive for premiums and cost-sharing. Always check with your state to ensure you are aware of any extra requirements your state may have.
Many Medicare sales agents have never sold a D-SNP, which leads them to assume that dual-eligible individuals are rare. It’s just the opposite!
20% of all Medicare enrollees are dual eligible. Ignoring this demographic means ignoring 1 in 5 Medicare sales opportunities.
CMS reports that in 2023, there were 12.5 million individuals simultaneously enrolled in Medicare and Medicaid.
40% of dual-eligible beneficiaries are under 65.
Most dual-eligible beneficiaries are eligible for full Medicaid benefits.
Typically, D-SNPs include the following:
Each state will inform the carriers what benefits they can include in their plans.
Most clients pay nothing for their D-SNP Plan as long as they maintain their Medicaid or LIS eligibility. There are potential costs associated with care, such as non-emergency ambulance rides, but there is no premium for the D-SNP itself.
Anyone who qualifies for a Medicare Savings Program is automatically enrolled in the Low-Income Subsidy (LIS) program, also called Extra Help. This helps qualifying individuals pay for their Part D prescription drugs.
Medicaid application options may include paper applications, online application submissions, and even in-person applications at the local State Medical Assistance (Medicaid) office. Visit www.medicare.gov to get the telephone number for the local Medicaid office.
To qualify for a D-SNP, a person enrolls in Medicare and applies for Medicaid separately. Once they’re eligible for both, they can enroll in a D-SNP online at www.medicare.gov, preferably with the help of an agent.
Dual eligibles can enroll and/or switch D-SNP plans during AEP. In addition, as of January 1, 2019, CMS allows beneficiaries to use the Special Election Period (SEP) for dual eligible and LIS individuals once per calendar quarter for the first 3 quarters of the year:
The quarterly usage is based on application date, not the effective date.
Example:
Coverage start date depends on your birthday if both apply:
Your coverage starts the first day of the month you turn 65. If your birthday is the first of the month, coverage starts the first day of the month before you turn 65.
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility
D-SNP enrollments and changes are effective the first of the month following the
application.
In order to enroll in a D-SNP plan, a beneficiary has to be enrolled in Medicare and Medicaid.
As with all things related to Medicaid, things can vary by state. Tennessee, for instance, doesn’t offer QMB+ or SLMB+, which are the versions of the Qualified Medicare Beneficiary and Specified Low-Income Medicare Beneficiary programs for recipients who also meet the requirements for their state’s Medicaid coverage. In 2023, 71.1% of duals had full benefits, and 28.9% had partial benefits, according to CMS.
Most but not everyone who is a full-benefit Medicare-Medicaid beneficiary is eligible for a Medicare Savings Program to help with cost-sharing assistance and Medicare premium assistance.
Entitled to Medicare Part A, only eligible for Medicaid under MSP.
Medicaid will pay:
• Medicare Part A premiums (if needed).
• Medicare Part B premiums.
• At the state option, certain premiums are charged by Medicare Advantage plans.
• Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program).
Entitled to Medicare Part A, only eligible for Medicaid under MSP.
Medicaid will pay:
• Medicare Part B premiums.
An individual entitled to Medicare Part A, with an income at least 120% FPL but less than 135% FPL, and resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid benefits.
Medicaid will pay:
An individual who has lost Medicare Part A benefits due to a return to work, but is eligible to enroll in and purchase Medicare Part A. The individual may not be otherwise eligible for Medicaid.
Medicaid will pay:
• Income limit varies by state.
An individual who does not meet the income or resource criteria for QMB or SLMB but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home and community-based waivers.
Medicaid will pay:
There are asset limits for each category of eligibility. Financial assets include things such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.
Check your local laws, but in most states there are certain resources that aren’t
counted as assets. These include:
Most but not everyone who is a full-benefit Medicare-Medicaid beneficiary is eligible for a Medicare Savings Program to help with cost-sharing assistance and Medicare premium assistance.
Entitled to Medicare Part A, only eligible for Medicaid under MSP.
Medicaid will pay:
• Medicare Part A premiums (if needed).
• Medicare Part B premiums.
• At the state option, certain premiums are charged by Medicare Advantage plans.
• Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program).
Entitled to Medicare Part A, only eligible for Medicaid under MSP.
Medicaid will pay:
• Medicare Part B premiums.
An individual entitled to Medicare Part A, with an income at least 120% FPL but less than 135% FPL, and resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid benefits.
Medicaid will pay:
An individual who has lost Medicare Part A benefits due to a return to work, but is eligible to enroll in and purchase Medicare Part A. The individual may not be otherwise eligible for Medicaid.
Medicaid will pay:
• Income limit varies by state.
An individual who does not meet the income or resource criteria for QMB or SLMB but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home and community-based waivers.
Medicaid will pay:
There are asset limits for each category of eligibility. Financial assets include things such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate.
Check your local laws, but in most states there are certain resources that aren’t
counted as assets. These include:
There are great ways to target the D-SNP market with mailers, but the most cost-effective way to generate D-SNP leads is through grassroots marketing. Some places to consider visiting are food pantries, soup kitchens, thrift stores, flea markets, churches, senior centers, and low-income housing communities.
Spend time volunteering, getting to know the management staff, and having conversations with anyone you meet at these spots. The best results will come when you visit these places regularly and don’t try to actively seek out prospects. People will find out and ask what you do, and lead generation will happen organically. Don’t try to be pushy. Educate and follow up.
By taking the time to explain options and coverages to clients, you set yourself up as a trusted advisor. Even after the sale, make sure you are available to your clients when they need help. Once your client is a member, make sure you ask for referrals by offering to help anyone else your client knows. Be sure to give clients several of your business cards.
If you want to generate D-SNP leads with business reply cards (BRCs), you will need to change your approach a bit if you are currently mailing to other groups. The most important change to make is the income brackets you are mailing to.
There are different income eligibility requirements for different D-SNP categories (we discuss those later). To get the best returns, you should mail to incomes around $15,000 or below to target Medicaid beneficiaries.
Most Medicare agents are busy buying T65 lists, but 40% of dual eligibles are under 65. That works out to 4.8 million people that your competitors are missing by only targeting 65+. You can market to this group with targeted lead mailers, or you can use social media (namely Facebook) to target a group with a specific area, age range, and interests.
Explain all options available to your prospective clients and make sure they understand what their status qualifies them for. Talk to them about provider
networks and drug tiers – most dual eligible clients are on several medications and see specific doctors. Enroll them in a plan that keeps costs as low as possible.
Stay in contact after the sale. Make sure your clients have seen their doctor(s) and filled their prescriptions. Answer any questions they have and address any issues they have come across. Revisit the value-added benefits of their plan, highlighting things like transportation, OTC programs and dental, as these benefits can make a big difference to a client with limited means.
Dual eligible clients rely on each other for information and guidance. When you become a trusted advisor to one, you can easily win over an entire community. Leave your business cards and ask them to hand them out when someone asks for healthcare advice. Ask for referrals every time you talk to your clients. The more you help, the more they will refer.
Medicare is a Federal program. Medicaid is a joint state and Federal program. Each state has its own Medicaid program and its own eligibility rules and benefits. A good reference can be found here.
With a few exceptions, you must be 65 or older to enroll in Medicare. With Medicaid,
the eligibility requirements include income level, need, and chronic conditions. There
are no age requirements for Medicaid, with a few exceptions, e.g., care specifically
for children.
Seniors must pay premiums to receive benefits for Medicare Part B, Medicare
Advantage, and Medicare Prescription Drug Plans (PDPs). Medicaid is free or
low-cost to eligible individuals.
Medicare Part A and B benefits are the same in every state. Not so with Medicaid
benefits. Medicaid is a joint state and Federal program. The Federal government
requires states to provide certain benefits, but each state decides whether to provide
other benefits.
Each state decides whether to provide these benefits.
Source: Medicaid.gov, Mandatory & Optional Medicaid Benefits
You got them, now keep them. Studies show it costs five times more to acquire a new customer than to retain one, and boosting retention by just 5% can increase profits by 25–95%.
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