Dual Eligible Special Needs Plans (D-SNPs / “Dual Complete” Plans)
Dual Eligible Special Needs Plans — commonly called D-SNPs or “Dual Complete” plans — are Medicare Advantage plans designed for individuals who qualify for both Medicare and Medicaid. These plans combine Medicare benefits with Medicaid cost-sharing protections, creating a unified structure for members who are dual eligible.
Overview
D-SNPs function as:
- Medicare Advantage (primary payer)
- Coordinated with Medicaid (secondary payer)
All D-SNPs must follow CMS rules, which means they retain:
- Medicare coverage criteria
- Medicare billing requirements
- Required MA cost-share structures (deductibles, copays, OOP limits)
Even though members rarely pay these costs, the structures must still exist.
Why D-SNPs Show Deductibles & Out-of-Pocket Limits
Even though Medicaid covers patient cost-sharing, D-SNPs still display deductibles, copays, and out-of-pocket maximums. This happens for three main reasons:
1. CMS Requires MA Plans to Include Cost-Sharing
All Medicare Advantage plans — including D-SNPs — must:
- List deductibles
- List copay/coinsurance amounts
- Include out-of-pocket maximums
These benefit structures must appear, even if the member qualifies for Medicaid.
2. Medicaid Acts as the Payer of Last Resort
Cost-sharing still exists in the claim, but Medicaid covers it on behalf of the patient.
The patient owes $0, but the system still uses the cost-share amounts to determine:
- What Medicare Advantage paid
- What Medicaid needs to cover
3. Claim Processing Requires Visible Cost-Sharing
During adjudication:
- The D-SNP applies deductible/coinsurance
- The system generates patient responsibility
- Medicaid uses that amount to determine payment
The cost-sharing numbers must exist to coordinate benefits correctly.
Billing Flow for Providers
- Submit claim to the D-SNP first
- D-SNP adjudicates using Medicare rules
- Deductible/copay/coinsurance is assigned (but not billed to the patient)
- Medicaid pays the cost-sharing as secondary
- Provider receives payment reflecting both portions
Important Note
If the D-SNP denies the service, Medicaid does not pay for it.
Medicaid only covers Medicare cost-sharing — not noncovered or denied services.
Key Characteristics of D-SNP Coverage
Medicare Rules Apply
D-SNPs must follow Medicare policies, including:
- LCD/NCD criteria
- Face-to-face documentation requirements
- Replacement schedules
- Prior authorization requirements (plan-dependent)
- Capped rental and purchase/rental rules
Medicaid Secondary Wrap
Medicaid typically covers:
- Deductibles
- Coinsurance
- Copayments
Medicaid does NOT cover items denied by the Medicare Advantage plan unless the item independently qualifies under that state Medicaid program (rare for most DME).
Prior Authorizations
D-SNPs commonly require PAs for services such as:
- CPAP/BiPAP devices
- Wheelchairs (manual, custom, power)
- Oxygen therapy
- Hospital beds
- Orthotics/prosthetics
- Most non-routine DME
Why This Structure Exists
D-SNPs were created to:
- Improve coordination between Medicare and Medicaid
- Protect low-income members from out-of-pocket costs
- Reduce fragmented care delivery
- Align financial responsibility across programs
- Support managed care oversight for dual-eligible populations
The result is a system where deductibles and OOP limits must exist, but Medicaid steps in to cover the cost-sharing.
Practical Summary for Providers
- Bill D-SNP first — it functions as Medicare Advantage.
- Expect cost-sharing to appear, but Medicaid pays it.
- Member responsibility is usually $0.
- If Medicare Advantage denies, Medicaid will not cover the claim.
- Prior authorizations are common and often required for DME.
| Medicare Advantage Plan | HHSC Contract Number | CMS Code | Plan ID | Plan Name | Type |
|---|---|---|---|---|---|
| Community First Health Plans, Inc. | HHS001466600001 | H5447 | 001 | CFHP Medicare Advantage Alamo Plan (HMO) | MAP |
| Community Health Choice Texas, Inc | HHS001466600002 | H9826 | 002 | Community Health Choice (HMO D-SNP) | MAP |
| Devoted Health Insurance Company of Texas, Inc | HHS001466600003 | H6813 | 001 | Devoted CHOICE GIVEBACK Austin (PPO) | MAP |
| Devoted Health Insurance Company of Texas, Inc | HHS001466600003 | H6813 | 002 | Devoted CHOICE Austin (PPO) | MAP |
| Devoted Health Insurance Company of Texas, Inc | HHS001466600003 | H6813 | 006 | Devoted LIBERTY CHOICE Austin (PPO) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 001 | Devoted CORE Greater Houston (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 002 | Devoted PRIME Greater Houston (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 003 | Devoted CORE San Antonio (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 004 | Devoted PRIME San Antonio (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 005 | Devoted BE WELL San Antonio (HMO-POS C-SNP) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 006 | Devoted GIVEBACK Greater Houston (HMO) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 007 | Devoted CORE El Paso (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 008 | Devoted GIVEBACK El Paso (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 014 | Devoted CORE Austin (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 019 | Devoted CORE 2 Greater Houston (HMO-POS) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 020 | Devoted LIBERTY San Antonio (HMO) | MAP |
| Devoted Health Plan of Texas, Inc. | HHS001466600004 | H7993 | 021 | Devoted GIVEBACK San Antonio (HMO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 009 | Cigna Courage Medicare (HMO | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 026 | Cigna Preferred Medicare (HMO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 061 | Cigna Preferred Medicare (HMO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 064 | Cigna Alliance Medicare (HMO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 074 | Cigna Preferred Medicare (HMO | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H4513 | 083 | Cigna Preferred Savings Medicare (HMO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7787 | 001 | Cigna Preferred Savings Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7787 | 002 | Cigna True Choice Courage Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7849 | 038 | Cigna True Choice Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7849 | 039 | Cigna True Choice Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7849 | 041 | Cigna True Choice Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7849 | 103 | Cigna True Choice Medicare (PPO) | MAP |
| HealthSpring Life & Health Insurance Company, Inc. | HHS001466600005 | H7849 | 134 | Cigna True Choice Medicare (PPO) | MAP |
| SelectCare of Texas, Inc. | HHS001466600006 | H4506 | 003 | Wellcare TexanPlus Classic No Premium (HMO) | nan |
| SelectCare of Texas, Inc. | HHS001466600006 | H4506 | 010 | Wellcare TexanPlus Patriot Giveback (HMO) | MAP |
| SelectCare of Texas, Inc. | HHS001466600006 | H4506 | 029 | Wellcare TexanPlus No Premium (HMO-POS) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 011 | Wellcare No Premium (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 012 | Wellcare Giveback (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 013 | Wellcare Complement Assist (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 014 | Wellcare Patriot No Premium (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 016 | Wellcare Complement Assist (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 017 | Wellcare No Premium (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 018 | Wellcare No Premium (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 019 | Wellcare Giveback (HMO) | MAP |
| Superior HealthPlan, Inc. | HHS001466600007 | H5294 | 020 | Wellcare No Premium (HMO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 002 | Wellcare Mutual of Omaha No Premium Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 003 | Wellcare Mutual of Omaha No Premium Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 006 | Wellcare No Premium Rx Plus Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 007 | Wellcare No Premium Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 009 | Wellcare No Premium Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 010 | Wellcare No Premium Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 011 | Wellcare Mutual of Omaha No Premium Secure Open (PPO) | MAP |
| WellCare National Health Insurance Company | HHS001466600008 | H7323 | 012 | Wellcare Mutual of Omaha No Premium Secure Open (PPO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 002 | Wellcare No Premium (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 009 | Wellcare Assist (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 010 | Wellcare No Premium (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 014 | Wellcare No Premium (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 015 | Wellcare No Premium (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 016 | Wellcare No Premium (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 017 | Wellcare Giveback (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 018 | Wellcare Giveback (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 019 | Wellcare Giveback (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 020 | Wellcare Giveback (HMO) | MAP |
| WellCare of Texas, Inc. | HHS001466600009 | H0174 | 021 | Wellcare Giveback (HMO) | MAP |
| Medicare Advantage | HHSC Contract Number | CMS Code | Plan ID | Plan Name | Type |
| Special Needs Plan | |||||
| MCO | |||||
| Aetna Better Health of Texas, Inc. | HHS001464900001 | H8597 | 001 | Aetna Medicare Dual Complete Plan (HMO D-SNP) | SNP |
| Aetna Better Health of Texas, Inc. | HHS001464900001 | H8597 | 002 | Aetna Medicare Dual Complete Plan (HMO D-SNP) | SNP |
| Aetna Better Health of Texas, Inc. | HHS001464900001 | H8597 | 003 | Aetna Medicare Dual Complete Plan (HMO D-SNP) | SNP |
| Aetna Health Inc. | HHS001464900002 | H4523 | 028 | Aetna Medicare Dual Preferred (HMO D-SNP) | SNP |
| Aetna Health Inc. | HHS001464900002 | H4523 | 029 | Aetna Medicare Dual Preferred (HMO D-SNP) | SNP |
| Aetna Health Inc. | HHS001464900002 | H4523 | 030 | Aetna Medicare Dual Preferred (HMO D-SNP) | SNP |
| Alignment Health Insurance Company of Arizona, Inc. | HHS001464900003 | H5472 | 007 | Alignment Health Dual Select+ (HMO-POS D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | H2406 | 050 | UHC Dual Complete TX-D001 (PPO D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | H5322 | 025 | UHC Dual Complete TX-D007 (HMO-POS D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | H5322 | 026 | UHC Dual Complete TX-V005 (HMO-POS D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | H5322 | 038 | UHC Dual Complete TX-V010 (HMO-POS D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | H5322 | 046 | UHC Dual Complete TX-S5 (HMO-POS D-SNP) | SNP |
| Care Improvement Plus South Central Insurance Company | HHS001464900004 | R6801 | 011 | UHC Dual Complete TX-S001 (Regional PPO D-SNP) | SNP |
| CHA HMO, Inc. | HHS001464900005 | H0028 | 031 | Humana Gold Plus SNP DE Tri-Metro Legacy DSNP | SNP |
| CHA HMO, Inc. | HHS001464900005 | H0028 | 032 | Humana Gold Plus SNP DE Dallas-DSNP | SNP |
| CHA HMO, Inc. | HHS001464900005 | H0028 | 033 | Humana Gold Plus SNP DE | SNP |
| Houston-DSNP | |||||
| CHA HMO, Inc. | HHS001464900005 | H0028 | 034 | Humana Gold Plus SNP DE | SNP |
| El Paso-DSNP | |||||
| CHA HMO, Inc. | HHS001464900005 | H0028 | 036 | Humana Gold Plus SNP DE | SNP |
| Corpus-San Antonio-DSNP | |||||
| CHA HMO, Inc. | HHS001464900005 | H0028 | 044 | Humana Gold Plus SNP DE | SNP |
| Austin-DSNP | |||||
| CHA HMO, Inc. | HHS001464900005 | H0028 | 045 | Humana Gold Plus SNP DE | SNP |
| RGV-DSNP | |||||
| Community First Health Plans, Inc. | HHS001464900006 | H5447 | 002 | CFHP Medicare Advantage D-SNP Standard Plan (HMO D-SNP) | SNP |
| Community Health Choice Texas, Inc. | HHS001464900007 | H9826 | 002 | Community Health Choice (HMO D-SNP) | SNP |
| Devoted Health Plan of Texas, Inc. | HHS001464900008 | H7993 | 010 | Devoted DUAL PLUS Greater Houston (HMO D-SNP) | SNP |
| Devoted Health Plan of Texas, Inc. | HHS001464900008 | H7993 | 012 | Devoted DUAL PLUS San Antonio (HMO D-SNP) | SNP |
| Devoted Health Plan of Texas, Inc. | HHS001464900008 | H7993 | 015 | Devoted DUAL PLUS Austin (HMO D-SNP) | SNP |
| Devoted Health Plan of Texas, Inc. | HHS001464900008 | H7993 | 017 | Devoted DUAL PLUS El Paso (HMO D-SNP) | SNP |
| El Paso First Health Plans, Inc. | HHS001464900009 | H3407 | 001 | El Paso Health Medicare Advantage Dual (HMO DSNP | SNP |
| Healthspring Life & Health Insurance Company, Inc. | HHS001464900010 | H4513 | 027 | Cigna TotalCare (HMO D-SNP) | SNP |
| Healthspring Life & Health Insurance Company, Inc. | HHS001464900010 | H4513 | 060 | Cigna TotalCare (HMO D-SNP) | SNP |
| Healthspring Life & Health Insurance Company, Inc. | HHS001464900010 | H4513 | 075 | Cigna TotalCare (HMO D-SNP) | SNP |
| HCSC Insurance Services Company | HHS001464900011 | H9706 | 002 | Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | SNP |
| Molina Healthcare of Illinois, Inc. | HHS001464900013 | H2715 | 002 | Molina Medicare Complete Care (HMO D-SNP) | SNP |
| Molina Healthcare of Texas, Inc. | HHS001464900014 | H7678 | 001 | Molina Medicare Complete Care (HMO D-SNP) | SNP |
| Physician’s Health Choice of Texas, LLC. | HHS001464900015 | H4527 | 003 | UHC Dual Complete TX-V002 (HMO-POS D-SNP) | SNP |
| Physician’s Health Choice of Texas, LLC. | HHS001464900015 | H4527 | 015 | UHC Dual Complete TX-D003 (HMO-POS D-SNP) | SNP |
| Physician’s Health Choice of Texas, LLC. | HHS001464900015 | H4527 | 054 | UHC Dual Complete TX-S4 (HMO-POS D-SNP) | SNP |
| Prominence HealthFirst of Texas, Inc. | HHS001464900016 | H7680 | 007 | Prominence Health Plan | SNP |
| Prominence HealthFirst of Texas, Inc. | HHS001464900016 | H7680 | 017 | Prominence Health Plan | SNP |
| Shared Health Insurance Company | HHS001464900017 | H2096 | 001 | Shared Health Dual Freedom | SNP |
| Superior HealthPlan, Inc. | HHS001464900018 | H5294 | 010 | Wellcare Dual Liberty Nurture (HMO D-SNP) | SNP |
| Superior HealthPlan, Inc. | HHS001464900018 | H5294 | 015 | Wellcare Dual Access Harmony (HMO D-SNP) | SNP |
| UnitedHealthcare Benefits of Texas, Inc. | HHS001464900019 | H0609 | 052 | UHC Dual Complete TX-D004 (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Benefits of Texas, Inc. | HHS001464900019 | H0609 | 065 | UHC Dual Complete TX-V007 (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Community Plan of Texas, LLC | HHS001464900020 | H4514 | 016 | UHC Dual Complete TX-D01P (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Community Plan of Texas, LLC | HHS001464900020 | H4514 | 018 | UHC Dual Complete TX-V01P (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Community Plan of Texas, LLC | HHS001464900020 | H4514 | 019 | UHC Dual Complete TX-V001 (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Community Plan of Texas, LLC | HHS001464900020 | H4514 | 021 | UHC Dual Complete TX-S003 (HMO-POS D-SNP) | SNP |
| UnitedHealthcare Community Plan of Texas, LLC | HHS001464900020 | H4514 | 023 | UHC Dual Complete TX-D002 (HMO-POS D-SNP) | SNP |
| WellCare National Health Insurance Company | HHS001464900021 | H7323 | 005 | Wellcare Dual Access Open (PPO D-SNP) | SNP |
| WellCare of Texas, Inc. | HHS001464900022 | H0174 | 004 | Wellcare Dual Access (HMO D-SNP) | SNP |
| WellCare of Texas, Inc. | HHS001464900022 | H0174 | 006 | Wellcare Dual Liberty (HMO D-SNP) | SNP |
| WellCare of Texas, Inc. | HHS001464900022 | H0174 | 022 | Wellcare Dual Reserve (HMO D-SNP) | SNP |
| WellPoint Insurance Company | HHS001464900025 | H8849 | 010 | Wellpoint Full Dual Advantage (HMO D-SNP) | SNP |
| WellPoint Insurance Company | HHS001464900025 | H8849 | 011 | Wellpoint Dual Advantage (HMO D-SNP) | SNP |
| Wellpoint Texas, Inc. | HHS001464900028 | H2593 | 044 | Wellpoint Full Dual Advantage 2 (HMO D-SNP | SNP |
| Wellpoint Texas, Inc. | HHS001464900028 | H2593 | 045 | Wellpoint Full Dual Advantage (HMO D-SNP) | SNP |
| Wellpoint Texas, Inc. | HHS001464900028 | H2593 | 046 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| Wellpoint Texas, Inc. | HHS001464900028 | H2593 | 047 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 032 | Wellpoint Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 048 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 049 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 051 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 053 | Wellpoint Full Dual Advantage (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 054 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| WellPoint Texas, Inc. | HHS001464900029 | H2593 | 056 | Wellpoint Full Dual Advantage 2 (HMO D-SNP) | SNP |
| Memorial Hermann Health Plan, Inc. | HHS001464900030 | H7115 | 005 | Memorial Hermann Advantage HMO | SNP |
| nan | end of table | nan | nan | nan | nan |