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Levels of D-SNP Eligibility Explained for Medicare Clients

Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed for people who qualify for both Medicare and Medicaid. These plans can be a tremendous help to clients who have limited income and resources, but understanding the levels of DSNP eligibility and plan types can sometimes be confusing.

As of 2025, understanding the levels of D-SNP eligibility and how they connect to different plan structures is more important than ever for agents. Here’s a simplified breakdown.

Full vs. Partial Dual Eligibility

Full Dual Eligible Members

• Who qualifies
  Clients in categories such as Qualified Medicare Beneficiary Plus (QMB+), Specified Low-Income Beneficiary Plus (SLMB+), or Full Benefit Dual Eligible (FBDE).
• What does this mean
  These are individuals with the highest financial or health-related needs. States decide who qualifies, often based on strict income, asset, or disability requirements.
• Why it matters in 2025:
  Only full dual members can use the monthly D-SNP Special Enrollment Period (SEP) if there’s a HIDE or FIDE plan in their area.

Partial Dual Eligible Members

• Who qualifies
  Categories include Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled Working Individual (QDWI).
• What does this mean?
  These members get some help with Medicare costs, such as Part B premiums, but they do not qualify for full Medicaid benefits.
• Why it matters:
  Partial duals can join certain D-SNPs, but they don’t have access to the monthly SEP; only the regular Medicare enrollment windows (AEP, OEP).

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Types of D-SNPs

D-SNPs are also categorized by how much Medicare and Medicaid benefits are integrated. Here’s what agents should know:

• Highly Integrated D-SNP (HIDE):
  • Covers Medicaid services such as behavioral health or long-term services and supports (LTSS).
  • As of 2025, the Medicaid contract must cover the D-SNP’s entire service area.
• Fully Integrated D-SNP (FIDE):
  • Combines both Medicare and Medicaid under one entity.
  • Must include primary and acute Medicaid services, plus LTSS (at least 180 days of nursing facility coverage).
  • Offers the highest level of integration and coordination between Medicare and Medicaid benefits.
• Applicable Integrated Plan (AIP):
  • A FIDE or HIDE plan with exclusively aligned enrollment.
  • Works directly with Medicaid managed care organizations tied to the D-SNP’s parent company.
• Coordination-Only D-SNP (CO):
  • Meets CMS minimum requirements but doesn’t integrate as fully as HIDE or FIDE plans.
  • Still required to coordinate Medicare and Medicaid services and share information between programs.
• Exclusively Aligned Enrollment (EAE):
  • Limits enrollment to full duals whose Medicaid is through the same company that operates the D-SNP.
  • Allows for better integration (single ID card, unified appeals and grievances, simplified materials).

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Why This Matters for Agents

• Enrollment rules are changing. As of 2025, only full duals with HIDE or FIDE plans in their service area can use the monthly SEP.
• Integration levels affect care. The more integrated the plan (like FIDE or HIDE), the easier it is for clients to navigate benefits and reduce confusion.
• Educating clients builds trust. Explaining eligibility clearly helps clients understand why they qualify (or don’t) for certain plans and enrollment periods.

The levels of D-SNP eligibility; full vs. partial, determine not just what benefits clients receive but also when they can enroll. On top of that, the type of D-SNP (HIDE, FIDE, CO, AIP) affects how well Medicare and Medicaid benefits work together.

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For agents, simplifying these distinctions is key. By guiding clients through their eligibility level and helping them choose the right type of D-SNP, you can ensure they get the maximum financial protection and coordinated care available.

What does Medicare Part C cover

If you watch TV, I’m sure you have heard about Medicare Part C.  Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B).  Private insurance companies offer these plans to beneficiaries.  In this post, we will answer the question; what does Medicare Part C cover.

Medicare Part C plans must cover all of the services that Original Medicare covers (except for hospice care, which is still covered under Part A), and they may offer additional benefits such as dental, vision, hearing, and prescription drug coverage. While Original Medicare (Parts A and B) offers essential coverage, many beneficiaries opt for additional benefits through Medicare Part C.

Basics of Medicare Part C coverage

Hospital insurance (Part A)

This includes inpatient hospital care, skilled nursing facility care, hospice care, and some home health care.

Medical insurance (Part B)

This includes doctor’s services, outpatient care, preventive services, and some DME (durable medical equipment).

Prescription drug coverage (Part D)

Many Medicare Advantage plans include prescription drug coverage.  Part D coverage is not part of Original Medicare.  When it is included in a Part C, Medicare advantage plan, it is called an MAPD plan.  If it is not included, the plan is called an MA only plan.

Additional benefits

Many Medicare Advantage plans offer additional benefits not covered by Original Medicare, such as routine dental, vision, and hearing care, fitness programs, transportation services, and over-the-counter allowances for certain health-related items.

More Medicare Part C Benefits

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Medicare dental benefits

Most people have heard about the additional benefits offered on some Medicare plans.  One of the most asked about benefits are Medicare dental benefits.  Although dental care is an integral part of overall health, in the vast landscape of healthcare, dental benefits are often overlooked.

The state of Dental coverage in Medicare:

Medicare plays a crucial role in ensuring individuals over the age of 65 and qualifying individuals with disabilities.  Unfortunately, the comprehensive healthcare coverage Medicare provides is definitely lacking when it comes to dental coverage.

As we have already mentioned, Medicare provides a great deal of coverage for various health services, yet dental care has traditionally held a separate status.  Neither Part A nor Part B (Original Medicare) cover routine dental care.  This includes things like check-ups, cleanings, fillings, and extractions.  These services can be quite expensive and many people on fixed incomes simply do not have the resources to afford the costly dental care they require.  This lack of coverage frequently leaves beneficiaries looking for supplemental options that will cover their oral health needs.

Medicare Advantage Plans with dental benefits:

These days, many people look to Medicare Advantage plans (Part C) to provide some relief from the high cost of dental work.  Medicare Advantage plans are offered by private insurers and often provide additional benefits beyond Original Medicare. Many Medicare Advantage plans include dental coverage.  This coverage usually includes preventive and a few additional services.  In some rare instances, more extensive treatments like root canals or dentures are also covered to some extent.

Learn about some of the plan comparison tools that help clients sort out their options

Stand-alone Dental Coverage:

Many Medicare beneficiaries ask about dental coverage because they understand the importance of dental health.  This is where you need to explain that supplementary (stand-alone) plans cater specifically to dental care needs.  There are many different options available and many dental insurance carriers. Each carrier provides a few different coverage options that include things like checkups, cleanings, fillings and various other dental procedures. It is imperative that beneficiaries understand dental plans only work well if they use an in-network provider for dental care. As an agent, you need to check that their dentist is in network with any plan they are considering.

click here to learn about the NCD metlife dental plans

The Importance of Routine Dental Care:

While navigating Medicare and dental benefits, it’s imperative to understand how important routine dental care is. Oral health can significantly impact overall well-being.  There are several studies that link poor oral health to various systemic conditions. Maintaining regular dental visits preserves a healthy smile and also contributes to overall health and quality of life.

Advocating for Future Changes:

Because of the critical role oral health plays in overall well-being, there’s an ongoing call for expanding Medicare to include comprehensive dental coverage.  Both advocates and policymakers continue to push for changes within the program to include preventive and restorative dental services.  The goal is to provide better access to essential oral healthcare for Medicare beneficiaries.

As the healthcare landscape continues to evolve, understanding the importance of Medicare dental benefits remains pivotal for individuals seeking comprehensive healthcare coverage.  Although the current scope of dental coverage in Medicare has many gaps, exploring supplemental options like Medicare Advantage plans or standalone dental coverage offer some help addressing oral health needs.

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What is a Medicare Advantage Plan

Original Medicare includes benefits for Part A (hospitalization) and Part B (doctor visits).  However, not all of a beneficiary’s needs may be satisfied.   (Click here to learn 5 things that are not covered.)  A Medicare Advantage Plan, also known as Medicare Part C or MAPD, can be an effective and financially smart way to ensure that senior citizens have the medical coverage they need going into their golden years.

While not part of the original federal health plan, Medicare Part C became law in 1982. The way it works is that the federal government pays private insurance companies a specific amount of money per person to bundle the original Medicare benefits. Many companies also add prescription drug coverage, or Medicare Part D, in their advantage plans. Some of these plans cover additional services than original Medicare, making them a smart choice for many senior citizens.

Because many Medicare Advantage plans work like private insurance plans, the options for them include:

• Health maintenance organization plans (HMOs)

• Preferred provider organization plans (PPOs)

• Private fee-for-service (PFFS)

Because of their connection to the federal plan, Medicare usually sets the fee for both the provider and the individual enrollee. But, for a PFFS plan, the private insurance company sets those fees. Medicare Advantage plans must follow Medicare rules and guidance from the federal government, though each private company can have different out-of-pocket costs or access to services. In addition, insurance companies can, and do, change the rules of their Medicare Part C (Advantage) plans each year.

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What will Medicare pay for

Because many people are unsure what will Medicare pay for, we are providing a quick summary of the parts of Medicare and what they cover.

Medicare is a federal health insurance program.  It provides coverage to people who are either 65 years or older, people with disabilities, and those with end-stage renal disease.  There are four parts of Medicare plans: Part A, Part B and Part C, as well as Part D.

What Medicare Part A pays for:

Part A or hospital insurance covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services.

1. Inpatient Hospital Stays: Part A pays for the cost of a semi-private room, meals, nursing care, and other hospital services and supplies. It also covers the cost of surgeries, anesthesia, and other medically necessary procedures.
2. Skilled Nursing Facility Care: If you need to stay in a skilled nursing facility for a short period after being discharged from the hospital, Part A covers the cost of a semi-private room, meals, nursing care, and therapy.
3. Hospice Care: If you have a terminal illness, Part A covers hospice care services, including pain relief, counseling, and medical care.
4. Home Health Care: Part A covers some home health care services if you are homebound and need skilled nursing care, physical therapy, or speech-language pathology services.

What Medicare Part B pays for:

Part B is also called medical insurance. It covers medically necessary services and preventive services that are not covered by Part A. Here’s what Part B pays for:

1. Doctor’s Services: This includes office visits, consultations, and surgical procedures.
2. Outpatient Services: Part B covers services that include diagnostic tests, laboratory services, and imaging tests.
3. Preventive Services: These services  include flu shots, cancer screenings, and annual wellness visits.
4. Durable Medical Equipment: Beneficiaries receive coverage for the purchase of durable medical equipment, including wheelchairs, walkers, and oxygen equipment.
5. Ambulance Services are covered if they are medically necessary.

What Medicare Part C pays for:

Medicare Part C or Medicare Advantage (MA plans). It is an alternative to Original Medicare, which includes Part A and Part B. Medicare Advantage plans are offered by private insurance companies. In most cases, they include additional benefits, such as vision, dental, and hearing coverage. Medicare Advantage plans must cover all the services that Original Medicare covers, but the cost-sharing and rules may be different.

What Medicare Part D pays for:

Some people refer to these plans as prescription drug coverage.  Private insurance companies offer this coverage to cover the cost of prescription drugs.  Part D plans typically have a formulary, which is a list of drugs that the plan covers. The cost-sharing and rules for Part D plans may vary.

In conclusion, Medicare covers a wide range of medical services.  This includes hospital stays, doctor’s visits, preventive care, medical equipment, and prescription drugs. Understanding what each part of Medicare covers can help you make informed decisions about your healthcare needs.

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AARP Medicare Complete is a general name given to a number of different United Health Care Medicare Advantage plans with the AARP logo.   United Healthcare also offers a number of different Medicare Complete plans without the AARP logo.

United has an AARP Medicare Complete branded product in most states.  In some states they have multiple plans.  The AARP branded Medicare Complete plans come in three types: HMO, POS and PPO.  The plans all have the same basic copay structure and more or less operate in the same manner with the only real difference being that the POS and PPO plans have out of network coverage.

Do you have other questions or do you want to see more detail on these plans?  I have a number of blogs on this topic or you may contact the office for more information.