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hands with puzzle pieces - dual special needs certified financial planning services ct
  • By Robert Dillard
  • Posted March 1, 2022

A Beginner’s Guide To Using Your Dual Special Needs Plan: Doctors And Costs

In this blog post, we are going to be answering some of the most commonly asked questions about Dual Special Needs Plans (DSNP’s). This is a blog post in a series all about DSNP plans and why they can be so valuable. We see so many of our clients miss out on benefits and care that they need and have access to just because DSNP plans are just too complicated or not well known enough, we’re here to change that!

You can find a basic introduction to DSNP plans here: https://planningacrossthespectrum.com/blog/medicare-dual-special-needs-use/

These plans are quite complicated and there are insurance specialists here at Planning Across the Spectrum who are ready and excited to help you figure them out! If you have any questions or concerns while or after reading this, reach out! And now for the questions that we will be answering in this blog post today:

Can I still use my current doctors?

We are happy to share that in most cases your current doctors will remain your doctors. The idea is that you work with a licensed insurance agent who will help you keep your doctors by helping you look at and sort through the array of different plans from the companies that offer them in your area! Typically, if you have a doctor that is taking your Medicaid plan you are still able to see them as Medicaid will still participate in your coverage with a DSNP. DSNP plans work best when the company you choose is also working with your current doctor for cost-related reasons that we will discuss shortly. Additionally, depending on where you live and the type of plan you chose, for example, if you pick a company that has a doctor you like but they do not take Medicaid, you can see them and will just be billed within the plan's coverage. Otherwise, Medicaid will cover that portion for you. DSNP plans are very flexible and designed to be heavily used, because of this even if your doctor isn’t in your network, you can pay to keep seeing them. DSNP plans are designed around giving you the flexibility to keep your current doctors, though it may come with extra costs. It’s worth noting however that DSNP plans often keep costs low, so let’s discuss how they do that.

What will this cost me?

Let’s start by discussing the general costs of a DSNP plan. This depends on a few factors, including having a good professional agent by your side (a trusted Certified Financial Planner doesn’t hurt either), but in general, you will not end up paying any more than you typically are or would be, and potentially much less. There are a few important costs to mention though. First, you may be asked to contribute a small premium, co-pay, or the remaining part of a bill if you see a provider that does not work with Medicaid. This is why finding a plan that includes the doctors you want to see is so vital. The largest factor to determine if you will have a cost-share is at what level you qualify for a DSNP. With that said there are various levels of qualifications which also depend on the state you are in. The most common eligibility levels are listed below. These are taken directly from the United States Government Website for the Centers for Medicare and Medicaid Services:

Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have an income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services are provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).

Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have an income of greater than 100% FPL, but less than 120% FPL and resources that do not

exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. FFP equals FMAP.

Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have an income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP.

Qualifying Individuals (1) (QI-1s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have an income of at least 120% FPL, but less than 135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. FFP equals FMAP at 100%.

These numbers and concepts are admittedly confusing, and sometimes it feels like they’re purposely so. Most of us are not used to having access to extra levels of care or two different plans that work together to offer different payment options. However, it's important to remember that these DSNP plans really aren’t that different than most health insurance plans in a lot of ways. The real differences only come into play when we discuss how you can have more flexibility over the services and care that you get. While this may not seem like the biggest difference, it is a big deal and has been extremely valuable to many. The flexibility is why we recommend looking into Dual Special Needs Plans to all who read these blog posts.

We often work with clients who qualify for DSNP plans but don’t know where to start and clients that don’t even know the plans exist at all. Even the clients that don’t understand the real value of these plans, and how Medicare and Medicaid can work together to make their lives easier. We hate to see people who need it missing out on important benefits that they qualify for and could be taking advantage of. This is true whether you are clients of ours or not, which is why we wrote this blog post! By reading this you have already taken an important step towards understanding how to get the most out of your health insurance, and that’s an important step worth being proud of. If DSNP plans sound like they might be for you, we fully encourage you to learn more.

We understand that this can still be quite overwhelming, but whether this blog post has helped you figure out exactly what you want or has just left you with further questions, don’t worry! You can contact a health insurance specialist who will do the work to find you a plan that suits your needs. Robert at Planning Across the Spectrum has helped many find the health insurance that is specifically right for them. By paying attention to what matters most Robert helps you find a plan that is mindful of your needs, your future, and current cost. We not only have the expertise, but also the passion and resources to help you achieve your financial goals your way

Contact Planning Across The Spectrum for certified special needs financial planning services and assistance with your Medicare Dual Special Needs Plan.


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