Answers to common Dual Special Needs plan (D-SNP) billing questions

An unexpected bill can be worrying, especially for those with a limited income. For Dual Special Needs plan (D-SNP) members, these bills often trigger several questions. If you’ve received an unexpected medical bill, here are answers to some of the questions you may have.

Some might assume that having both Medicare and Medicaid makes everything free. Having both does mean coverage for a wide range of health care services. But there are some circumstances that may lead to a bill.

If you receive a bill from your provider, start by reading it carefully. Your provider may not have the correct insurance information. If that’s the case, a phone call to the provider’s office should clear things up.

If your provider accepts Medicaid patients, ensure they aren’t billing you in addition to Medicaid. Providers that accept Medicaid cannot bill patients for services.

If your provider doesn’t accept Medicaid patients, the service you received would be considered out of network. This means that Medicaid will not cover the cost. Those with D-SNP should verify that their provider accepts Medicaid before treatment.

What looks like a bill could also be your explanation of benefits (EOB). The EOB is a statement that lets you know a claim has been filed. The EOB will include a detailed breakdown of costs and what you might owe. Always review the EOB to ensure no mistakes were made.

Patients receive an invoice from a provider's office if Medicaid isn’t billed correctly. Again, a call with the provider’s office should clear up this issue.

If you receive a treatment that isn’t covered by your Medicare or Medicaid benefits, you’ll be responsible for the coinsurance.

You may also need to verify whether you still qualify for your state’s Medicaid coverage or Qualified Medicare Beneficiary (QMB) status. If you’ve lost coverage or no longer qualify as a QMB, you will be responsible for the Medicare coinsurance.

If you receive a bill, it could be because your Medicaid has lapsed. This can be a surprise for dual-eligible enrollees. A change of income, missed paperwork, or a life event could cause you to lose eligibility.

If you lose your Medicaid eligibility at some point during the year, the Medicare portion of your plan will still provide coverage. But without Medicaid coordination, you’ll be responsible for cost sharing, including copays, coinsurance, and deductibles.

Many D-SNPs offer $0 cost sharing. This means that enrollees pay nothing for covered medical services. Because Medicare and Medicaid coordinate to pay for benefits, plan members are not responsible for coinsurance, copays, or deductibles.

Some plans also offer $0 cost sharing on benefits not usually covered by Original Medicare, such as dental, vision, and hearing services.

Providers that accept Medicaid patients agree to be reimbursed by Medicaid only. This means that providers are not allowed to bill Medicaid members for extra costs of covered services. Billing a patient and receiving a Medicaid reimbursement is known as balance billing and is prohibited.

With the end of the Value-Based Insurance Design model, plan providers are no longer permitted to offer $0 cost sharing for prescription drugs. Fortunately, the low-income subsidy program known as “Extra Help” can cover almost all prescription drug costs. If you’re enrolled in both Medicare and Medicaid, you will be enrolled in Extra Help automatically.

In 2026, those with Extra Help pay no plan premium and no plan deductible. Additionally, those with Extra Help will only pay up to $5.10 for generic drugs and $12.65 for brand-name medications. Once you’ve paid $2,100 for the year (including some costs paid for by Extra Help), you’ll pay $0 for prescription drugs.

The Medicare Prescription Payment Plan (MPPP) is an optional payment option for prescription medications. With the MPPP, your out-of-pocket prescription drug costs are spread out throughout the year and you’ll be billed monthly.

Note that if you qualify for the Part D low-income subsidy known as Extra Help, the MPPP may not be a good fit.

If you receive an unexpected bill, read it over before doing anything else. It’s possible the bill was sent in error. Check to see if your provider used your D-SNP coverage.

If you spot an error, contact your health care provider. Connect with the billing department to ensure your plan is applied.

If your health care provider is confident you were billed correctly, contact your insurance provider by calling the number on the back of your ID card. UnitedHealthcare D-SNP members can find this number on their back of their UCard.

If you suspect your health care provider may be balance billing, contact the Centers for Medicare & Medicaid Services’ “No Surprises Help Desk” at 1-800-985-3059 or submit a complaint online at https://www.cms.gov/medical-bill-rights/help/submit-a-complaint.