Dual-Eligible Special Needs Plans (D-SNPs) are a critical component of the healthcare landscape for individuals who are dually eligible for both Medicare and Medicaid. These individuals, often facing complex health needs and limited financial resources, require coordinated care to navigate the complexities of both systems. In 2021, approximately 12.9 million people in the U.S. were dually enrolled in Medicare and Medicaid, highlighting the significant population that relies on these integrated programs. D-SNPs are designed to address the unique needs of this population by offering specialized Medicare Advantage plans. This article delves into ten essential aspects of D-SNPs, providing a detailed overview of their enrollment trends, availability, benefits, and operational characteristics.
Dual-eligible individuals represent a diverse group, with varying demographics and healthcare requirements. Nearly half are people of color, and a substantial portion are under the age of 65. These individuals often experience more extensive and complex healthcare needs compared to the average Medicare enrollee. The coordination between Medicare and Medicaid is crucial for this population, as navigating two separate systems can be challenging and lead to fragmented care.
Medicare serves as the primary insurer for dual-eligible individuals, offering coverage through traditional Medicare or Medicare Advantage plans. Medicaid typically acts as a supplementary payer, covering Medicare premiums, cost-sharing, and additional benefits not covered by Medicare, such as long-term services and supports. However, the intricate eligibility rules, benefits, and regulations of both Medicare and Medicaid can result in a disjointed healthcare experience for dual eligibles. This complexity underscores the importance of D-SNPs, which are specifically designed to streamline and coordinate care for this vulnerable population.
In 2023, 5.2 million dual-eligible individuals were enrolled in D-SNPs, reflecting the growing significance of these plans. D-SNPs are mandated to enhance the coordination of Medicare and Medicaid benefits compared to standard Medicare Advantage plans. This enhanced coordination aims to improve the overall healthcare experience and outcomes for dual-eligible individuals. These plans often include benefits beyond those offered in traditional Medicare and typically do not require an additional premium, making them an attractive option for eligible individuals.
This guide will explore ten key facets of D-SNPs, drawing upon comprehensive data to illustrate national and state enrollment patterns, plan accessibility, insurer involvement, benefit structures, and the landscape of prior authorization and denials. While D-SNPs hold promise for improving care coordination, it is important to note that a minority of enrollees are in fully integrated plans, raising questions about the extent of true integration between Medicare and Medicaid within the D-SNP framework. Furthermore, data limitations hinder a complete assessment of D-SNP quality and the utilization of extra benefits, highlighting areas for future research and improvement.
1. D-SNP Enrollment: Nearly One-Third of Dual Eligibles
In 2021, approximately 29% of dual-eligible individuals were enrolled in D-SNPs. This figure represents a significant increase from 2010, when only 11% of dual eligibles were enrolled in these specialized plans. The growth in D-SNP enrollment underscores the increasing recognition of these plans as a valuable option for coordinated care.
As of 2023, the majority of D-SNP enrollees (57%) are in coordination-only (CO) plans. These plans are designed to provide a foundational level of coordination between Medicare and Medicaid, but they do not fully integrate the two systems within a single plan structure. Another 35% of D-SNP enrollees are in highly integrated dual eligible (HIDE) SNPs. HIDE SNPs build upon the requirements of CO plans and incorporate coverage for critical services such as long-term services and supports, and behavioral health services, offering a more comprehensive level of integration. The remaining 8% of D-SNP enrollees are in fully integrated dual eligible (FIDE) SNPs. FIDE SNPs represent the highest level of integration, aiming to coordinate all Medicare and Medicaid benefits within a single managed care organization, offering a seamless care experience for enrollees.
2. State-Level Variations in D-SNP Enrollment
The proportion of dual-eligible individuals enrolled in D-SNPs varies considerably across states. In 2021, state enrollment rates ranged from a low of 5% in Nevada to a high of 58% in Hawaii, compared to the national average of 29%. Seven states exhibited particularly high D-SNP enrollment rates, with 40% or more of their dual-eligible populations enrolled in these plans. These states include Alabama (42%), New York (42%), Florida (46%), Tennessee (46%), Arizona (47%), and Hawaii (58%), along with Puerto Rico (98%, data not shown in mainland state comparisons). Conversely, states like Nevada (5%) and Montana (8%) had D-SNP enrollment rates below 10%, indicating significant state-level differences in adoption and penetration of these plans. Nevada had D-SNPs become available for the first time in 2021, which may explain the lower initial enrollment rate.
Between 2018 and 2021, D-SNP enrollment more than doubled in 19 states, indicating rapid growth in many regions. States with initially lower D-SNP enrollment rates in 2018, such as Oklahoma, Iowa, and West Virginia, experienced the most significant percentage growth in D-SNP enrollment by 2021. For instance, Oklahoma saw an increase from 1% in 2018 to 12% in 2021. In contrast, states like Arizona, California, Hawaii, Massachusetts, and Minnesota maintained relatively stable D-SNP enrollment rates during this period. Interestingly, New Mexico, Oregon, and Utah were the only states that saw a decrease in D-SNP enrollment share between 2018 and 2021. Insurers in Alaska, Illinois, New Hampshire, Wyoming, Vermont, North Dakota, and South Dakota did not offer D-SNPs in either 2018 or 2021, contributing to lower Medicare Advantage enrollment overall in these states, which partially explains the low D-SNP enrollment.
These state-level variations in D-SNP enrollment are likely influenced by a combination of factors. State policies regarding D-SNP enrollment, the demographic characteristics of the dual-eligible population in each state, the strategic decisions of insurance firms, and the capacity to establish effective care networks for dual-eligible individuals all play a role in shaping these differences.
3. County-Level Variations Within States
D-SNP enrollment rates also exhibit significant variation within states at the county level. For example, in Northern California in 2021, San Francisco County had a D-SNP enrollment rate of 20% among dual-eligible individuals, while neighboring Santa Clara County had a rate of only 5%. Similarly, despite having comparable numbers of dual-eligible individuals, Alameda County had a D-SNP enrollment rate of 16%, whereas Sacramento County’s rate was more than double at 34%. In Florida, Orlando (Pasco County) had a D-SNP enrollment rate of 54%, compared to 64% in nearby Tampa (Osceola County). However, counties in the Florida Panhandle showed much lower enrollment rates, such as 24% in Jackson County and 45% in adjacent Gadsden County. In Puerto Rico, D-SNP enrollment is nearly universal across counties.
These county-level variations may be attributed to factors such as the degree of rurality and Medicare payment rates, which can influence plan availability and attractiveness in different geographic areas. Rural counties may face challenges in establishing provider networks, while varying payment rates can affect insurer participation and plan offerings.
4. D-SNP Availability: Broad Access Across Counties
In 2022, the vast majority of dual-eligible individuals, over 92%, resided in a county where at least one D-SNP was offered. This represents an increase in access compared to 2018, when 86% of dual eligibles had access to a D-SNP. The expansion of D-SNP availability indicates a growing effort to provide these specialized plans to a wider geographic area, enhancing access for dual-eligible individuals across the country. The remaining 8% of dual-eligible individuals without D-SNP access primarily lived in the five states where D-SNPs were not available in 2022: Illinois, New Hampshire, South Dakota, Vermont, and Alaska.
5. Number of D-SNP Options: Increasing Choice
The average dual-eligible individual had a choice of 10 D-SNPs in 2022, marking a record high number of options and more than double the number available in 2011. This increase in plan choices reflects the growing market for D-SNPs and the expanding participation of insurers. However, plan availability still varies significantly by county. For instance, dual eligibles in metropolitan New York City had access to as many as 40 D-SNP options, while those in neighboring Suffolk County had 17 choices. In contrast, states like Wyoming and Montana offered only one D-SNP option. Individuals in Illinois, North Dakota, New Hampshire, Vermont, and Alaska continued to lack access to D-SNPs in 2022 and will also not have access in 2024, highlighting persistent geographic disparities in plan availability.
6. Dominant D-SNP Insurers: UnitedHealthcare and Humana
In 2023, UnitedHealthcare and Humana emerged as the leading providers of D-SNPs, collectively accounting for 52% of total D-SNP enrollment. UnitedHealthcare alone represented nearly two-fifths (37%) of all D-SNP enrollees, surpassing the combined enrollment of major insurers such as BCBS, Centene, Elevance Non-Blue, CVS Health, Kaiser Permanente, and Cigna (31%).
Between 2018 and 2023, the market share of smaller firms in the D-SNP sector declined from 27% to 17%, indicating a consolidation of enrollment among larger, established insurers. During this period, the enrollment share of Kaiser Permanente, Cigna, Centene, BCBS, and Elevance Non-Blue decreased, while UnitedHealthcare, CVS Health, and Humana experienced growth in their D-SNP enrollment share, solidifying their positions as market leaders. Humana’s focus on member-centric care models and integrated healthcare solutions positions them strongly in the D-SNP market, potentially aligning with the goals of “care highlight programs” that emphasize personalized and coordinated care for vulnerable populations.
7. Expansion of D-SNP Offerings by Major Insurers
Every major insurer in the D-SNP market expanded their plan offerings between 2018 and 2024. In plan year 2024, insurers are offering a total of 851 D-SNPs, more than double the 401 plans offered in 2018. This growth is driven by insurers increasing their plan offerings in existing counties and expanding into new counties.
Eight major insurers account for 75% (638) of all D-SNPs in 2024, up from 68% in 2018, further indicating market concentration. The remaining 25% (213) of plans are offered by smaller insurers. CVS Health demonstrated the most significant growth, increasing its D-SNP offerings by 98 plans since 2018, reaching 105 plans in 2024. Kaiser Permanente had the smallest growth among major insurers, adding 5 plans since 2018, with a total of 10 plans in 2024.
Florida Complete Care is a new entrant to the D-SNP market in 2024, although it has offered other types of SNPs previously. Conversely, five firms (Ascension, Health Choice Generations Utah, AgeWell New York, Essence Healthcare, and Vantage Health Plan) are exiting the D-SNP market, indicating some level of market dynamism and consolidation.
8. Enhanced Benefits in D-SNPs
D-SNPs are more likely to offer certain supplemental benefits compared to standard individual Medicare Advantage plans. While core benefits like eye exams/eyeglasses (96%), dental care (95%), fitness benefits (94%), and hearing exams/aids (92%) are nearly universally offered in both D-SNPs and individual Medicare Advantage plans in 2024, D-SNPs stand out in providing additional support services.
Specifically, D-SNPs are more likely to offer over-the-counter benefits (96% vs. 85%), meal benefits (86% vs. 72%), bathroom safety devices (32% vs. 22%), and in-home support services (23% vs. 9%) compared to individual Medicare Advantage plans. Transportation services are also significantly more prevalent in D-SNPs (88% vs. 36%). Many of these extra benefits may be covered by Medicaid as “Medicaid wraparound services,” and D-SNPs may expand upon these state-provided services. However, the extent to which D-SNP benefits supplement or duplicate existing Medicaid services varies and is not fully understood. These enhanced benefits in D-SNPs are crucial for addressing the social determinants of health and complex needs of dual-eligible individuals. Programs highlighting these care benefits align with the intent of D-SNPs to provide comprehensive support.
9. Prior Authorizations in D-SNP-Only Contracts
In 2021, dual-eligible individuals enrolled in D-SNPs within D-SNP-only contracts were subject to an average of one prior authorization request per year. It’s important to note that CMS publishes prior authorization data at the contract level, not by plan type, limiting the ability to analyze data specifically for all D-SNP enrollees. This analysis focuses on D-SNP-only contracts, which represent about 19% of total D-SNP enrollment. The majority of D-SNP enrollees (81%) are in contracts that include other types of Medicare plans, for which CMS does not publish separate prior authorization data.
Firms with D-SNP-only contracts received an average of one prior authorization request per beneficiary in 2021, which is lower than the 1.5 requests per enrollee across all Medicare Advantage plans. This is somewhat unexpected given the higher healthcare utilization typically observed among dual-eligible individuals. However, CVS had a higher rate of prior authorization requests in D-SNP-only contracts compared to their overall Medicare Advantage contracts. Among firms with D-SNP-only contracts, prior authorization requests ranged from less than one per beneficiary (UnitedHealthcare) to 2.2 per beneficiary (BCBS).
10. Higher Denial Rates in D-SNP-Only Plans
Despite fewer prior authorization requests in D-SNP-only plans compared to all Medicare Advantage plans, the denial rate was significantly higher. In 2021, D-SNP-only contracts had a prior authorization denial rate of 12%, double the 6% denial rate for all Medicare Advantage plans. This translates to nearly 670,000 denied prior authorization requests within D-SNP-only contracts. Denial rates varied among firms, ranging from 5% (Humana) to 15% (CVS Health and Centene) in D-SNP-only contracts.
Of the denied prior authorization requests in D-SNP-only contracts, nearly 7% were appealed, compared to 11% for all Medicare Advantage plans. However, the success rate of appeals was lower in D-SNP-only contracts, with 68% of appeals resolved favorably, compared to over 82% for all Medicare Advantage contracts. This suggests potential challenges in accessing necessary care within D-SNP-only plans, despite the lower volume of initial prior authorization requests. The higher denial rates warrant further investigation to ensure equitable access to care for dual-eligible individuals within these specialized plans.
Discussion
D-SNP enrollment has seen substantial growth, with nearly 3 in 10 dual-eligible individuals enrolled in 2021, up from 20% in 2018. This growth is likely driven by several factors. The enhanced benefits offered by D-SNPs, particularly those exceeding standard Medicare Advantage plans like over-the-counter items and meals, are attractive to dual eligibles. Insurers also show strong interest in D-SNPs, potentially due to favorable profit margins. The market has responded with increased insurer participation and plan offerings. Automatic enrollment policies may also contribute to enrollment growth. In 2022, D-SNP access was widespread, with over 92% of dual eligibles living in counties with at least one D-SNP and an average of 10 plan options available, compared to just 6 in 2018.
However, despite growth in enrollment and availability, the effectiveness of D-SNPs in coordinating care with Medicaid remains unclear. Less than 10% of D-SNP enrollees are in fully integrated plans, raising concerns about the level of true integration. Similarly, assessing the quality of D-SNPs is challenging due to data limitations. Quality ratings are reported at the contract level, not the plan level, affecting the majority of D-SNP enrollees (81%) who are in contracts with other plan types. Furthermore, concerns exist about the adequacy of current quality measures for D-SNPs. Early quality assessments have yielded mixed results, with some studies showing limited quality variations between plans and others finding little difference in care quality between D-SNPs and other care models for dual eligibles.
Data transparency issues also hinder understanding the impact of prior authorization in D-SNPs. While analysis of D-SNP-only contracts suggests higher denial rates compared to overall Medicare Advantage, the lack of comprehensive data on all D-SNP enrollees limits a full assessment. Similarly, while extra benefits are commonly offered, data is lacking on the utilization and value of these benefits for dual eligibles with diverse health needs. Concerns have also been raised about marketing tactics that may promote benefits already available through Medicaid, potentially creating confusion for beneficiaries.
Given the significant needs of the dual-eligible population and the incentives for D-SNP growth, gaining deeper insights into the experiences of D-SNP enrollees is crucial for both beneficiaries and policymakers. Proposed policy changes, such as Special Enrollment Periods to boost D-SNP participation, further emphasize the need for comprehensive data and oversight to ensure these plans effectively serve their intended purpose of providing coordinated, high-quality care for dual-eligible individuals. Focusing on programs that highlight care coordination and enhanced benefits, like those potentially offered by Humana, could be key to improving the value and effectiveness of D-SNPs in the future.
This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.
Salama Freed, Meredith Freed, Jeannie Fuglesten Biniek, Nolan Sroczynski, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant.
| Box 1: Medicare and Medicaid in Puerto Rico |
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| Puerto Rico is included in this analysis of dual-eligible individuals in Medicare. Notably, Puerto Rico’s Medicare and Medicaid programs differ from the 50 states and the District of Columbia. In Puerto Rico, nearly all Medicare beneficiaries are enrolled in a Medicare Advantage plan. Medicare Advantage penetration is higher across Puerto Rico than in the 50 states and District of Columbia. In 2023, at least 90% of eligible Medicare beneficiaries are enrolled in a Medicare Advantage plan across virtually all Puerto Rican counties. In particular, enrollment in D-SNPs accounts for a much larger share of Medicare Advantage enrollment than in any of the 50 states or the District of Columbia. For this reason, data for Puerto Rico is not shown on the maps for Figures 2 and 3. Puerto Rico’s Medicaid program eligibility rules, benefits, delivery system and financing differ in some ways from those in the 50 states and the District of Columbia. For example, Puerto Rico does not cover most of the benefits that full-benefit dual-eligible individuals use such as long-term services and supports, and in Puerto Rico, cost-sharing assistance is provided to full-benefit dual-eligible individuals, but not to partial-benefit dual-eligible individuals, because Medicare Savings Programs are not available in Puerto Rico. Methods for identifying dual-eligible individuals in Puerto Rico differed than in other states and DC. Please see methods in the following KFF analysis: How Do Dual-Eligible Individuals Get Their Medicare Coverage? |
| Methods and Limitations |
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| This analysis uses data from the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Benefit and Landscape files for the respective year. Dual-eligible beneficiary enrollment is based on analysis of the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse (CCW) research-identifiable Master Beneficiary Summary File (MBSF) Base. The estimates are based on data from 5 percent of beneficiaries, 2010-2016; CCW data from 20 percent of beneficiaries, 2017-2021. The most recent snapshot of the dual-eligible population was available in 2021. D-SNP enrollment data are from the Special Needs Plan (SNP) data published by CMS in the Medicare Advantage (MA)/Part D Contract and Enrollment Data section in March of the respective year. Enrollment data are only provided for plan-county combinations that have at least 11 beneficiaries; thus, we exclude any plans that do not meet this enrollment threshold. We excluded D-SNPs that were sanctioned by CMS, as these plans had no enrollment. The 2021 count of dual-eligible individuals includes the 11.5 million individuals who had Parts A and B who were dual-eligible in March 2021. Other KFF analysis also require individuals to have Parts A and B, but allow them to be dual eligible at any point during the year, and thus have 12.9 million dual-eligible individuals in 2021. Counts of dual-eligible individuals and D-SNP enrollees include both full-benefit and partial-benefit dual eligible individuals. Partial-benefit dual eligibles are eligible to enroll in D-SNPs in all but 7 states (Arizona, Hawaii, Idaho, Massachusetts, Minnesota, New Jersey, and Oregon). A limitation of this analysis is partial-benefit dual eligible individuals are not excluded from those 7 states when evaluating access to a D-SNP from 2010 to 2022. Supplemental benefits in Medicare Advantage and Dual Special Needs Plans were identified using the 2023 Quarter 4 Centers for Medicare & Medicaid Services (CMS) Plan Benefit Package data. KFF defines a plan as offering a benefit if it is available to enrollees as either a mandatory or optional supplemental benefit. Optional supplemental benefits require an additional premium, which KFF does not examine in this analysis. KFF also does not examine all the extra benefits that Medicare Advantage and D-SNPs offer – for example, special supplemental benefits for the chronically ill. Prior authorization data were obtained from organization determinations and reconsiderations – Part C data from the Centers for Medicare and Medicaid Services (CMS) Part C and D reporting requirements public use file for contract year 2021. Medicare Advantage insurers submit the required data at the contract level to CMS and CMS performs a data validation check. For the 2021 plan year, 114 contracts did not pass the data validation process, including all contracts for Elevance Blue Cross Blue Shield plans, and are excluded from this analysis. This analysis reflects data on service determinations and does not include claims determinations (for payment for services already provided). This analysis also does not include withdrawn or dismissed determination requests. KFF identified D-SNP-Only contracts by merging the plan-county enrollment data and plan type data. If all plans in the contract are a D-SNP, no matter the coordination type, this is considered a D-SNP-Only contract. |
