Tip for D-SNP Model Enrollment Form

D-SNP plans are designed for people who have BOTH Medicare and Medicaid (dual eligibles)

Tip for D-SNP Model Enrollment Form

These plans often have $0 premiums, $0 copays, and extra benefits like dental, vision, and transportation

Tip for D-SNP Model Enrollment Form

You can switch between D-SNP plans quarterly — you are not locked in for the full year

Medicaremoderate

D-SNP Enrollment Form

D-SNP Model Enrollment Form · CMS

Enrollment form for Dual-Eligible Special Needs Plans (D-SNPs) for individuals with both Medicare and Medicaid coverage.

Form Details

Total fields: 40
Auto-fillable: 30 (75%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: annual

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Where to Submit This Form

🌐

Medicare.gov Plan Finder

https://www.medicare.gov/plan-compare/

Search for D-SNP plans in your area.

📬

Mail the plan's enrollment form

Contact the D-SNP plan for their enrollment form.

🏢

Through a licensed insurance agent, SHIP counselor, or at a plan enrollment event

Filing Deadline

D-SNP enrollees often have a Special Enrollment Period every calendar quarter (Jan-Mar, Apr-Jun, Jul-Sep) in addition to the Annual Enrollment Period (Oct 15 - Dec 7).

Required Attachments

📎 Medicare Part A and Part B card or number
📎 Proof of Medicaid eligibility (Medicaid card or eligibility letter)
📎 Completed D-SNP enrollment form

Processing Time

14 days for enrollment processing. Coverage starts the first of the month after enrollment.

What Happens Next

You will receive plan membership materials. The D-SNP will coordinate your Medicare and Medicaid benefits under one plan.

Tips for This Form

✓ D-SNP plans are designed for people who have BOTH Medicare and Medicaid (dual eligibles)
✓ These plans often have $0 premiums, $0 copays, and extra benefits like dental, vision, and transportation
✓ You can switch between D-SNP plans quarterly — you are not locked in for the full year
✓ Verify that your state Medicaid eligibility is current before enrolling

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