Why Is Coordination of Coverage Important When You Have Both Medicare and Medicaid?
What Is a DSNP?
Shanti
8/20/20263 min read
Why Is Coordination of Coverage Important When You Have Both Medicare and Medicaid?
Some individuals qualify for both Medicare and Medicaid at the same time. These individuals are known as dual eligible beneficiaries. Having both programs can reduce healthcare costs and provide access to additional services. However, if the two types of coverage are not coordinated properly, the individual may experience problems such as an unexpected loss of benefits, unanticipated expenses, or confusion between insurance companies.
What Is the Difference Between Medicare and Medicaid?
Medicare is a federal program that primarily covers individuals age 65 and older, as well as certain younger individuals with disabilities or specific medical conditions.
Medicaid is a joint federal and state program. Eligibility is determined based on income, assets, household circumstances, and the laws of each state.
For an individual who has both types of coverage, Medicare is generally the primary payer for covered services. Medicaid may help pay some Medicare premiums, deductibles, copayments, and other eligible costs. The exact level of assistance and available services depends on the individual’s eligibility and state regulations.
What Is Medicaid Enrollment Churn?
States periodically review an individual’s eligibility to continue receiving Medicaid. Medicaid coverage may be terminated if a renewal form is submitted late, documentation is incomplete, income temporarily changes, or an administrative error occurs, even when the individual remains eligible
When coverage is terminated and the individual enrolls again within a short period, it is called enrollment churn. This can have significant consequences, including:
Loss of Medicaid assistance with Medicare costs
Loss of the Medicare Savings Program
Disruption of enrollment in a D SNP
Suspension or limitation of home care and support services
New premiums, copayments, or medical bills that the individual cannot afford
Disrupted access to physicians, medications, medical transportation, or ongoing care
According to a report published by the Medicare Rights Center, administrative problems and delays in Medicaid renewals can cause several months of lost coverage and increased healthcare expenses, even for individuals whose financial circumstances have not changed.
What Is a D-SNP?
A Dual Eligible Special Needs Plan, also known as a D SNP, is a type of Medicare Advantage plan designed specifically for individuals who qualify for both Medicare and Medicaid.
These plans may make it easier to coordinate benefits between the two programs. Depending on the plan and the individual’s location, they may also provide supplemental benefits such as dental, vision, hearing, transportation, or allowances for certain over the counter items.
However, not all D SNP plans are the same. The level of coordination between Medicare and Medicaid, provider networks, drug formularies, supplemental benefits, and costs can vary from one plan to another. Some plans provide only limited coordination, while others offer greater integration between Medicare and Medicaid services.
Is Every Plan That Resembles a D SNP a Suitable Choice?
No. Similar plan names or advertisements promoting benefits such as shopping cards, transportation, or dental services are not enough to determine whether a plan is appropriate.
Before enrollment, the following should be reviewed:
Is the individual actually eligible for that D SNP?
Are the individual’s physicians, hospitals, and pharmacies included in the plan’s network?
Are the individual’s medications included in the plan’s formulary?
Will the individual’s Medicaid coverage coordinate with the same plan or insurance company?
How are transportation and home care services provided?
What eligibility requirements and limitations apply to supplemental benefits?
If prior authorization is required, how does the approval process work?
Could enrollment in the new plan disrupt any current benefits?
How Can an Unintentional Loss of Coverage Be Prevented?
Individuals who have both Medicare and Medicaid should:
Report any changes in address, telephone number, income, or household circumstances promptly.
Pay attention to all Medicaid letters and notices.
Submit renewal documents before the deadline and keep proof of submission.
Regularly check the status of their Medicaid coverage and Medicare Savings Program.
Before changing D- SNP plans, review the provider network, covered medications, and coordination with Medicaid again.
If coverage is terminated incorrectly, promptly ask about filing an appeal, restoring coverage, or enrolling again.
Contact Us
Reach out anytime for personalized support
Phone
© 2025. All rights reserved.