Introduction
Dual Eligible Special Needs Plans (D-SNPs) offer a crucial healthcare solution for individuals eligible for both Medicare and Medicaid. By integrating benefits from both programs, D-SNPs provide streamlined, coordinated care that reduces gaps and confusion. This approach gives enrollees access to comprehensive services, including medical, dental, vision, and home support, ensuring their needs are met more effectively. Designed to simplify healthcare for dual eligibles, D-SNPs focus on improving health outcomes, enhancing care quality, and reducing costs.
Understanding Dual Eligibles and Their Challenges
Dual eligibles are individuals who qualify for both Medicare, primarily for seniors and people with disabilities, and Medicaid, which provides assistance based on income. There are over 9 million people who fall into this category, and their needs are often complex due to chronic illnesses, disabilities, and socioeconomic challenges. However, since Medicare and Medicaid operate separately, coverage and care are frequently fragmented.
As a result, dual eligibles are left to navigate different insurance cards, rules, and provider networks. With Medicaid acting as the “payer of last resort,” it only covers services not provided by other insurers, including Medicare.
Role of Medicare Advantage and D-SNP Plans
Medicare Advantage plans are private alternatives to Medicare that often include additional benefits like dental and vision care. D-SNPs, or Dual Eligible Special Needs Plans, are a subset of these plans specifically designed for dual eligibles, intended to integrate Medicare and Medicaid benefits more effectively.
Expansion of D-SNPs and Supplemental Benefits
D-SNPs have grown rapidly, with enrollment increasing from 1.5 million in 2014 to over 6 million in 2024. These plans offer supplemental benefits that many dual eligibles find attractive, including dental, vision, hearing, home care, and meal assistance. However, these additional services come at a significant cost—about $64 billion annually—and often overlap with Medicaid benefits, creating confusion and barriers to access.
Issues with Overlapping Medicare and Medicaid Coverage
The overlapping benefits between D-SNPs and Medicaid can make it difficult for dual eligibles to understand which plan covers specific services. For instance, D-SNPs may provide short-term home care as a benefit following hospitalization, while Medicaid may cover similar services for long-term support. The lack of clear coordination results in beneficiaries being unsure of where to seek support, leaving some needs unmet.
Challenges Faced by Dual Eligibles in Navigating Benefits
Coordination Silos and Their Impact
The existing silos between Medicare and Medicaid are a significant barrier to coordinated care. D-SNPs are intended to streamline services, yet most are not fully integrated with Medicaid. As a result, the responsibility for managing care is unclear, leading to gaps in service and high healthcare costs. Although dual eligibles make up a small portion of both programs, they account for over 30% of spending due to complex health and social needs.
Lack of Transparency in Benefits
One of the biggest challenges in D-SNPs is the lack of transparency in benefits. Plans often promote supplemental benefits, such as meal delivery or home support, but eligibility restrictions and limits are not always clear. Marketing practices sometimes obscure these limitations, leading dual eligibles to enroll in plans without fully understanding their coverage, only to discover later that certain services are restricted or capped.
Recommended Reforms for Better Integration of Medicare and Medicaid
To address these challenges, Eric T. Roberts and colleagues have outlined several recommendations to improve the effectiveness of D-SNPs for dual eligibles.
Enhancing Medicare-Medicaid Coordination in D-SNPs
Roberts suggests that state Medicaid agencies should leverage D-SNP contracts with insurers to require better coordination between Medicare and Medicaid coverage. This would allow dual eligibles to receive services seamlessly without having to determine which program covers what. By holding insurers accountable for coordinating care, states can ensure dual eligibles use their benefits more effectively.
Improving Transparency in Benefits Information
The lack of clarity around D-SNP benefits can be addressed by increasing transparency in the Medicare Advantage plan finder. Providing dual eligibles with access to information on their potential Medicaid benefits, alongside clear eligibility criteria, would help individuals make more informed choices about their coverage.
Effective Tracking and Monitoring of Benefits Usage
Accurate tracking and monitoring of benefits usage are critical for ensuring that the funds allocated to D-SNPs are effectively used. To improve oversight, Roberts recommends that Centers for Medicare and Medicaid Services (CMS) require insurers to report on the specific use of supplemental benefits at the member level. This would allow CMS to monitor how supplemental benefits are used, keep insurers accountable, and ensure taxpayer dollars support better health outcomes.
Progress and Future Changes in Medicare-Medicaid Integration
In response to these challenges, CMS is implementing reforms aimed at simplifying the D-SNP landscape. Beginning in 2025, CMS will notify Medicare Advantage beneficiaries annually about any unused supplemental benefits they qualify for, helping them access services more effectively. CMS also plans to limit the number of D-SNPs an insurer can offer and extend enrollment periods, making it easier for dual eligibles to select plans that best meet their needs.
Conclusion
Integrating Medicare and Medicaid for dual eligibles is essential to providing comprehensive, equitable healthcare to millions of Americans. Although D-SNPs offer valuable supplemental benefits, the lack of coordination between Medicare and Medicaid can create confusion, limiting access to needed services. By implementing reforms such as improved coordination, transparency, and oversight, policymakers can streamline healthcare for dual eligibles, ensuring they receive the full benefits they deserve.
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FAQs
1. What is a Dual Eligible Special Needs Plan (D-SNP)?
Ans: D-SNPs are Medicare Advantage plans designed to provide coordinated benefits to individuals eligible for both Medicare and Medicaid.
2.Why is integration of Medicare and Medicaid important?
Ans: Integration reduces fragmentation, simplifies access to benefits, and ensures dual eligibles receive comprehensive, coordinated care without gaps or overlaps.
3.What reforms are proposed for D-SNPs?
Ans: Proposed reforms include improved coordination between Medicare and Medicaid, increased transparency, and better tracking of benefit usage.
