Dual Eligible Special Needs Plans for Medicare and Medicaid Enrollees - Revised FAQs for Contract Year 2025

Individuals who are eligible for or have both Medicare and Medicaid are what is called dual eligible—they are “dual eligible” for both health care programs. Dual eligible individuals must meet the federal qualifications for Medicare eligibility and the QUEST Integration (QI)-specific qualifications for Medicaid eligibility.

Some dual eligible individuals qualify for all Medicare and Medicaid benefits. These individuals are called full benefit dual eligible individuals (FBDE). Others qualify for all Medicare benefits, but do not qualify for all Medicaid benefits. They may only receive assistance with Medicare premiums, copays, and deductibles. These individuals are called partial benefit dual eligible individuals. 

A Dual Eligible Special Needs Plan is a Medicare Advantage plan that has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals. D-SNPs include requirements that the plan help coordinate Medicaid benefits for the member. 

There are five D-SNPs in Hawaii, all of which also operate a QI Medicaid Managed Care Organization (MCO). These organizations operating the five D-SNPs are: AlohaCare, HMSA, Kaiser, Ohana, and United.  

In Hawaii, only full benefit dual eligible (FBDE) individuals, including those in the Qualified Medicare Beneficiaries (QMB) Plus and Specified Low-Income Medicare Beneficiary (SLMB) Plus programs, and other FBDE individuals can enroll in a D-SNP. QMB Plus enrollees qualify for full Medicaid benefits, and receive Medicaid assistance with their Medicare Part A and B premiums and cost sharing. Enrollees in SLMB Plus similarly qualify for full Medicaid benefits, but receive Medicaid assistance for Medicare Part B premiums only.   

In 2025, Hawaii will have two types of D-SNPs: Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs), and Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs).

• It is important to note that to enroll in a FIDE SNP, individuals must be enrolled in the same organization’s QI MCO, in what is called aligned enrollment (See Question 11).
• This is different from HIDE SNPs, where an individual can be enrolled in one organization’s HIDE SNP for their Medicare benefits, and another organization’s QI MCO for their Medicaid benefits (See Question 7).

A HIDE SNP is a type of D-SNP in Hawaii that has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals and also has a contract with MQD to provide coverage of primary, acute, and most all behavioral health, and long-term services and supports (LTSS) benefits.

Note that there are some Medicaid behavioral health and LTSS benefits that HIDE SNPs do not provide for certain dual eligible individuals.

• Dual eligible individuals with intellectual/developmental disabilities (I/DD) who receive LTSS via the state’s 1915(c) home- and community-based (HCBS) I/DD waiver; and/or
• Dual eligible individuals with serious mental illness (SMI) who receive behavioral health services exclusively through Ohana’s Community Care Services (CCS) program.

Question 15 provides further detail for how individuals with I/DD and/or individuals with SMI enrolled in the CCS program will have their needs further coordinated and supported by both FIDE SNPs and HIDE SNPs in 2025.

Three organizations will offer a HIDE SNP in 2025. These organizations include: AlohaCare, Ohana, and United. HMSA and Kaiser will not offer a HIDE SNP in 2025.

Note that United will offer two different HIDE SNP options in 2025:

• One that meets HIDE SNP requirements noted in Question 14; and
• One that meets FIDE SNP requirements (See Question 8), including ‘exclusively aligned enrollment’ (See Question 12) and providing members with a single ID card and a single care manager who can manage across all services.

In Hawaii, FBDE individuals including those in the QMB Plus and SLMB Plus programs, and other FBDE individuals can enroll in a HIDE SNP.

Unlike enrollment into a FIDE SNP (See Question 10), dual eligible individuals can be enrolled in one organization’s HIDE SNP for their Medicare benefits, and another organization’s QI MCO for their Medicaid benefits.

• Note that enrollment into UnitedHealthcare Dual Complete HI-Y1 (UnitedHealthcare's unique HIDE SNP option for 2025), is limited to those meeting FIDE SNP enrollment requirements in Question 10.

In Hawaii, a FIDE SNP is a type of D-SNP that, like the HIDE SNP, has a model of care and benefits designed specifically to serve the unique needs of dual eligible individuals and contracts with MQD to provide coverage of primary, acute, and most behavioral health, and LTSS benefits.

In addition to these requirements, FIDE SNPs must also provide members with a single ID card, a single care manager who can manage across all services, an integrated provider and pharmacy directory and formulary reflecting their Medicare and Medicaid benefits and services, one customer service line for talking to someone about their Medicare and Medicaid coverage, and one process for filing plan-level Medicare and Medicaid appeals and grievances.

FIDE SNPs also give members a more streamlined care experience through what is known as ‘exclusively aligned enrollment’ (See Question 11 and Question 12).

Of the five Hawaii D-SNPs, four will offer a FIDE SNP in 2025. These organizations are: AlohaCare, Ohana, Kaiser, and HMSA. United will offer a unique HIDE SNP option in 2025, UnitedHealthcare Dual Complete HI-Y1, that meets all FIDE SNP requirements and offers members the same streamlined care experience as other FIDE SNPs in Hawaii (See Question 8).

Like enrollment into HIDE SNPs, FBDE individuals, including those in the QMB Plus and SLMB Plus programs, and other FBDE individuals can enroll in a FIDE SNP in Hawaii.  

Unlike enrollment into HIDE SNPs, individuals whose Medicare benefits and Medicaid benefits are provided under different organizations will not be eligible to enroll in FIDE SNPs. To enroll in a FIDE SNP, an individual’s Medicare D-SNP and QI Medicaid MCO must be ‘aligned’ under the same organization (See Question 11). This means that a dual eligible individual must be enrolled in a QI MCO in order to enroll in the same organization’s FIDE SNP.

Aligned enrollment is when an individual’s QI MCO and D-SNP are through the same organization. This makes their QI Medicaid benefits and Medicare benefits more coordinated, compared to separate organizations providing coverage of each benefit package. This can make for a more streamlined care experience for the member. Members may elect to align their enrollment in either a FIDE SNP or HIDE SNP.

As noted in Question 11, aligned enrollment can occur based on an individual’s choice in either FIDE SNPs or HIDE SNPs.

However, a key difference between FIDE SNPs and HIDE SNPs is that FIDE SNP enrollment is limited to only those dual eligible individuals whose QI MCO and Medicare D-SNP are aligned under the same organization. This enrollment into FIDE SNPs is referred to as ‘exclusively aligned’, because enrollment is limited exclusively to aligned individuals.

Dual eligible individuals exclusively aligned in FIDE SNPs can expect more seamless experiences across Medicare and Medicaid, compared to even those dual eligible individuals whose enrollment is aligned in HIDE SNPs. This is because a FIDE SNP’s entire membership is receiving Medicare and Medicaid benefits from the same organization, which allows them to provide members a single ID card for both Medicare and Medicaid benefits, an integrated provider and pharmacy directory, an integrated formulary, one health plan customer service number, a single care manager who can manage across all services, one process for appeals and grievances, and more seamless care coordination with most all benefits covered under the same organization.

However, timing will be important for dual eligible individuals wishing to enroll in a FIDE SNP, as exclusively aligned enrollment in Hawaii requires that a dual eligible individual must first be enrolled in a QI MCO in order to enroll in the same organization’s FIDE SNP.

For example, a dual eligible individual wishing to enroll in a FIDE SNP, but whose QI and Medicare benefits are provided by different organizations, would first need to request to enroll in the QI MCO offered by the same organization that offers their desired FIDE SNP enrollment choice. In most cases, MQD limits QI MCO changes to the Rolling Plan Change period, in which all QI members are allowed to change their QI MCO enrollment at any time without cause, after twelve (12) months of continuous membership in a particular QI MCO. This means that most new enrollments into FIDE SNPs will be limited to those already enrolled with their QI MCO for 12 months and therefore eligible to change QI MCO to match their desired FIDE SNP.

There are some circumstances where dual eligible individuals may enroll in a FIDE SNP outside of the QI Rolling Plan Change period. For example, a dual eligible individual whose Medicare and Medicaid enrollment is aligned under their current HIDE SNP would be able to enroll into that organization’s FIDE SNP throughout the year as long as they have an available Medicare Special Election Period (SEP).

HIDE SNPs and FIDE SNPs are similar in some areas, and different in others. Click here to view a high-level comparison of the key features.

* Note that United will offer a unique HIDE SNP option in 2025, [insert specific plan name for UHC EAE HIDE SNP as noted in the table in the ‘Member’ tab], that meets all FIDE SNP requirements and offers members the same streamlined care experience as other FIDE SNPs in Hawaii.

There are some Medicaid behavioral health and LTSS benefits that neither FIDE SNPs nor HIDE SNPs provide for certain dual eligible individuals. These include:

• Services for dual eligible individuals with I/DD who receive LTSS via the state’s 1915(c) HCBS I/DD waiver; and/or
• Services for dual eligible individuals with serious mental illness who receive behavioral health services exclusively through Ohana’s CCS program.

Both, FIDE SNPs and HIDE SNPs provide greater care coordination for these dual eligible individuals who, despite being enrolled in a FIDE SNP or HIDE SNP, may still have to navigate across two or even three different organizations for their Medicare and Medicaid benefits. Care coordination enhancements for these dual eligible individuals include D-SNP staff education and training for how individuals receive services from CCS or the I/DD Waiver, and required D-SNP care managers to serve as a point of contact to help enrollees’ coordinate across their D-SNP and CCS and/or I/DD Waiver services. This single care manager will manage both the individual’s FIDE SNP and QI MCO services and benefits.