5 Things to Know About Picking a Dual Health Plan

Choosing the right individual health insurance coverage is important at any age — but if you qualify for both Medicare and Medicaid, finding the right dual health plan can make a big difference in your healthcare and budget.

Also called a Dual Eligible Special Needs Plan or DSNP, a dual health plan is designed specifically for people who qualify for both programs.

DNSP plans offer more than just basic coverage. They help coordinate your care, reduce your out-of-pocket costs, and often include extra benefits to support your everyday health needs.

If you’re considering a dual health plan, here are five key things to keep in mind to help you make an informed decision.

1 — Understand what a dual health plan covers

Dual Eligible Special Needs Plans are a specialized type of Medicare Advantage plan (Medicare Part C) designed for individuals who qualify for both Medicare and Medicaid. These Medicare health insurance plans are built to coordinate your benefits and fill in the gaps that might exist if you were only enrolled in one program.

A typical DSNP includes:

• Doctor and hospital coverage (just like Original Medicare Part A & Part B)
• Prescription drug coverage (usually Medicare Part D is included)
• Care coordination services to help manage chronic conditions or complex health needs

But that’s not all. The goal is to give you better care, better service, and more value—all in one simple plan. Many plans go beyond the basics with valuable extras, such as:

• Dental, vision, and hearing benefits
• Transportation to medical appointments
• Over-the-counter (OTC) allowances for health items like pain relievers, vitamins, and cold medicine
• Fitness programs and wellness support

2 — Know your eligibility and what’s offered in your area

To enroll in a Dual Eligible Special Needs Plan, you must meet two key requirements:

1. Be enrolled in Medicare Part A and Part B
2. Qualify for Medicaid in your state

The exact rules and Medicaid benefits can vary from state to state, so your eligibility and available plans may depend on where you live.

Also, dual health plans aren’t the same everywhere. Insurance companies offer different plans in different counties or regions. That’s why it’s important to check what’s available in your ZIP code, not just what’s advertised on TV or online.

You can search for plans using Medicare’s Plan Finder at Medicare.gov, or work with a licensed insurance agent, like the experts at The Baldwin Group, who understand the options in your area.

3 — Consider extra benefits that matter to you

One of the biggest advantages of a DNSP is access to extra benefits that go beyond what Original Medicare or standard Medicaid typically offer. But not all plans include the same extras, and not every extra benefit may be important to you.

Take time to think about what matters most:

• Do you need regular rides to doctor appointments?
• Would dental or vision coverage save you money?
• Could you use a monthly allowance to buy health products?
• Would a care manager or nurse help you stay on track with medications?

Make a list of your health priorities and day-to-day needs. Then compare plans to see which ones offer the benefits that match your lifestyle.

These added services can make a real difference in your comfort, independence, and confidence in your healthcare.

4 — Watch for changes in costs and provider networks

Even though DNSP plans are designed to be low-cost, or even $0, for people with Medicare and Medicaid, it’s still important to look at the fine print when comparing your options.

Here are a few things to review:

• Copayments and cost-sharing: Some plans offer $0 copays for certain services, while others may charge small fees for these services.
• Network of doctors and hospitals: Make sure your current providers are in-network to avoid switching.
• Pharmacy access: Check if your preferred pharmacy is included, and if your medications are on the plan’s drug list (also known as a formulary).

Plan details can change from year to year, including what’s covered and which providers are included. Reviewing these changes annually can help you avoid surprises and ensure you keep the coverage that works best for you.

5 — Not all DNSP plans are the same—know what to compare

Although DNSP plans are designed for individuals with both Medicare and Medicaid, not all plans offer the same level of support, coverage, or additional benefits. That’s why it’s important to go beyond the basics when comparing your options.

Here are a few things that can vary widely between plans:

• Care coordination services: Some plans offer assistance with managing medications, appointments, and follow-ups, while others don’t.
• Extra benefits: Dental, vision, hearing, transportation, and over-the-counter allowances vary by plan.
• Access to specialists: Some plans have stronger provider networks or better access to local specialists.
• Customer support and service: A plan might look good on paper but fall short when it comes to real help when you need it.

Dual coverage, one easy path forward

DSNPs are unique Medicare health insurance plans designed to serve individuals who are enrolled in both Medicare and Medicaid. If you’re eligible for both, a dual health plan can offer powerful advantages — from extra benefits to more coordinated care. But choosing the right plan requires some research.

To recap:

1. Know what’s covered.
2. Check your eligibility and local plan options.
3. Look for the benefits that match your needs.
4. Review costs and provider access.
5. Know what to look for when comparing plans

At The Baldwin Group, we’re here to make navigating Dual Eligible Special Needs Plans (DSNPs) as simple and stress-free as possible. Whether you’re exploring options for yourself or for a loved one, our team is committed to helping you find the right health coverage to fit your unique situation.

Want to take the next step? Call us at 248.717.1423 or connect with a Baldwin Group advisor online to learn more.