About However, this group of people share some common characteristics, such as limited financial means and health care needs that are more wide-ranging and complex than the average Medicare enrollee. Prior KFF research has described the complex landscape of coverage options available to dual-eligible individuals when enrolling in Medicare and Medicaid. Medicare, the primary source of health insurance coverage for dual-eligible individuals, may be provided under traditional Medicare or a Medicare Advantage plan.
Medicaid, which typically wraps around Medicare, covers the cost of Medicare premiums and in many cases, cost sharing assistance. Full dual-eligible individuals are also eligible for benefits not otherwise covered by Medicare, such as long-term services and supports. Dual-eligible individuals may receive Medicaid benefits through fee-for-service or managed care , and coverage and eligibility vary by state.
In , 5. D-SNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes. D-SNPs typically provide benefits not otherwise available in traditional Medicare and generally do not charge a premium.
This brief highlights 10 things to know about D-SNPs, including national and state enrollment trends, plan availability, insurer participation, benefits, and prior authorization rates and denials, based on data from various sources see methods for details. In addition, gaps in data make it difficult to assess the quality of D-SNPs, prior authorization rates and denials by type of service, and the extent to which extra benefits are used. The share of dual-eligible individuals enrolled in D-SNPs more than doubled in 19 states between and States with relatively low D-SNP enrollment relative to the dual-eligible population in , such as Oklahoma, Iowa, and West Virginia, had the highest percentage growth in share of dual-eligible individuals enrolled in D-SNPs between and New Mexico, Oregon, and Utah were the only states where a smaller share of dual-eligible individuals enrolled in D-SNPs in compared to Overall, Medicare Advantage enrollment in these states tends to be lower than the national average, partially explaining the relatively low enrollment among dual-eligible individuals in D-SNPs.
Differences in D-SNP enrollment across states may be reflective of several factors, including variation in: state-level policies pertaining to D-SNP enrollment, demographic characteristics of the dual-eligible population in the state, firm strategy, and the ability to establish care networks for dual-eligible individuals. Within states, D-SNP enrollment among dual-eligible individuals often varies by county. Variations in D-SNP enrollment at the county level may be attributed to several factors, such as rurality and Medicare payment rates.
