Medicare Advantage D-SNP (HMO) FAQs

A Dual Eligible Special Needs Plan offers several benefits beyond what Medicare or Medicaid provides individually. D-SNPs include extra services like $0 copays for many doctor’s visits and regular dental, vision, and hearing exams, free transportation assistance, and gift cards to buy over-the-counter health & wellness items. D-SNPs also provide personalized care coordination to help manage complex medical needs. Community First Medicare Advantage D-SNP has a $0 premium, allowing you to keep your existing Medicaid benefits. Overall, D-SNPs deliver more comprehensive and customized care for Members.

D-SNP plans are for people diagnosed with certain conditions or diseases, or those with low incomes. Eligibility is determined by the state and the federal government.

To be eligible for a Dual Eligible Special Needs Plan (D-SNP), you must meet the following requirements:

Medicaid

·       You must qualify for Medicaid benefits. Medicaid eligibility is based on your financial status, including income and assets, which vary by state. Learn more.

Medicare

·       You must qualify for Medicare Parts A and B (Original Medicare). You may qualify if you are at least 65 years old, or if you are younger than 65 and have a qualifying disability or other special situation. 

Citizenship

·       You must be a U.S. citizen or a legal resident who has lived in the U.S. for at least 5 years in a row. 

Location

·       You must live in the coverage area for the D-SNP. The coverage area for Community First Medicare Advantage D-SNP includes Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, and Wilson counties.

• Medicare Open Enrollment from October 15-December 7 for coverage starting January 1.
• Initial Enrollment Period, a seven-month period that begins three months prior to the month containing your 65th birthday. It includes the entire month of your birthday and continues for three months after that month.
• Special Enrollment Period (SEP). For certain situations that happen in your life, like moving to a new address, losing or changing your current coverage, getting Medicaid, or needing to sign up for extra help to pay drug costs, you may be eligible for a SEP. Some qualifying events that can qualify you to enroll in a DSNP during this period include:
• Nursing Home Residency. Whether you are moving in, moving out, or are currently living in a nursing home, you can enroll in a Special Needs Plan for the first time, you can switch plans, or opt out of one you are currently enrolled in.
• Medicaid qualification. If you already have Medicaid benefits or become eligible, you can enroll in a Special Needs Plan anytime.
• If you move outside the service area covered by your current Special Needs Plan and you want to switch to another plan, you can do it during the SEP. If you do not enroll in a different D-SNP, you are automatically returned to coverage through Original Medicare.
• Your D-SNP leaves Medicare. At this time, you can sign up for a different D-SNP.

 Learn more about Special Enrollment Periods. 

Community First Medicare Advantage D-SNP Members pay $0 for their monthly premium and have a $0 deductible for Part A and Part B services. There is a deductible for Part D drugs.

For most Members, there are little to no out-of-pocket costs. Medicaid may help cover copays and other qualifying costs. Check the D-SNP Evidence of Coverage, Summary of Benefits, and other plan documents for specific cost details.

Community First Medicare Advantage D-SNP includes prescription drug coverage (Part D). You can view our drug formulary (a list of covered drugs) online or request a copy by contacting Member Services.

Community First offers access to an extensive network of doctors, specialists, and facilities that accept Community First Medicare Advantage D-SNP. You can find a provider by using our online Provider Directory. If you’d like a printed copy, call Member Services at 1-833-434-2347, and we’ll mail you one at no cost.

Yes. We offer non-emergency transportation at NO COST through our transportation partner MTM to/from the doctor, dentist, hospital, or pharmacy.

If you lose Medicaid eligibility, you may have to pay for costs normally covered by your Medicaid plan. You would also be eligible for a Special Enrollment Period to change your Medicare Advantage Plan because losing eligibility for Medicaid is a qualifying event for a Special Enrollment Period.

Your D-SNP plan will automatically renew each year as long as you remain eligible for both Medicare and Medicaid. It’s important to ensure that your Medicaid status is up to date to avoid any gaps in coverage.

Medicare is a federal health insurance program primarily for people aged 65 and older, but it also covers some younger individuals with disabilities. It has different parts: Part A (hospital insurance), Part B (medical insurance), and Part D (prescription drug coverage). Medicare is not income-based. Members may have to pay premiums, deductibles, and copays.

Medicaid is a state and federal program that offers health coverage to individuals and families with low income. It covers a wider range of services, often with little to no cost for eligible individuals. Some people qualify for both Medicare and Medicaid, which is known as being “dual-eligible”.

When you have both Medicaid and Medicare (dual-eligible), Medicare is your primary coverage. This means Medicare will pay first for your medical services, such as doctor visits, hospital stays, and prescriptions. After Medicare pays its share, Medicaid may help cover the remaining eligible costs, such as copays, deductibles, and services that Medicare doesn’t cover, like long-term services and supports (LTSS) or additional home health services.

Community First Medicare D-SNP plans cover all services that Medicare and Medicaid cover, including your Part A (Hospital Insurance for inpatient and outpatient hospital stays) and Part B (Medical Insurance for preventive care). In addition, our plan covers Part D (Prescription Drug Coverage for prescription medications), PLUS extra benefits like:

• Dental Coverage
• Vision Coverage
• Hearing Coverage
• Fitness Memberships
• Health & Wellness Programs
• 24/7 Nurse Advice Line
• Virtual Doctor Visits (Telehealth)
• Care Coordination (Organizing patient care and sharing information among the patient, family, doctors, and all concerned parties)
• Prepaid Card for Over-the-Counter Items
• Non-Emergency Transportation Services (NEMT)
• At-Home Meal Delivery Services
• Personal Emergency Response System
• Yearly Limit on Out-of-Pocket Costs
• Access to Nationally Recognized Specialists
• Access to a Level I Trauma Center
• Local, In-Person Member Services Support

View plan documents and other Member Resources here.

Yes, Community First Medicare Advantage D-SNP includes dental coverage for the following:

• Preventive services like oral exams, cleanings, fluoride treatments, dental x-rays
• Comprehensive services like diagnostic services, restorative services, periodontics (treatment for conditions that affect the tissues around your teeth, such as bone loss, and gum disease) extractions, prosthodontics (dentures, crowns, bridges, and implants), oral surgery, and other non-routine services.

There is no copay or deductible for dental services. A dental benefit limit does apply. You can find your dental benefit limit in your plan documents. If you need help finding a dental provider, please call Member Services at 1-833-434-2347.

Yes, Community First Medicare Advantage D-SNP includes vision coverage for the following:

• Eye exams to treat conditions of the eye, one routine eye exam per year, and eyewear (glasses and contact lenses)
• Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration
• One glaucoma screening each year for people who are at high risk of glaucoma
• For people with diabetes, one screening for diabetic retinopathy per year
• One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens

 There is no copay or deductible for vision services. Vision benefit limits do apply. You can find your vision benefit limit in your plan documents. If you need help finding a vision provider, please call Member Services at 1-833-434-2347.