Dual Eligible Special Needs Plans (D-SNPs)

On this page: 

Consider Highmark Wholecare

D-SNP Options

SSBCI Eligibility

How D-SNP Works

Get Help 

Considering Highmark Wholecare D-SNP

If you’re looking for new health care coverage or want to change your current health plan, Highmark Wholecare helps save time and money while staying healthy.

Eliminating Benefits Paperwork

If you’re changing your current coverage to a D-SNP, changing to your new plan will be completed for you.

Using Expansive Network

For your convenience, our D-SNP coverage is accepted by thousands of board-certified doctors throughout Pennsylvania.

Earning Heathy Rewards

The Goodness Rewards Program helps you earn gift card rewards for over 100 locations when you complete healthy activities.

Your D-SNP Choices

Your Dual Eligible Special Needs Plan (D-SNP) is Medicare Part A and Part B, Medicaid, medication benefits and more. You can choose between our Diamond D-SNP and Ruby D-SNP if you:

• Have been on disability for the past 2+ years
• Are age 65 or older
• Have Medicare Part A, Medicare Part B and Medicaid cards
• Live in our Pennsylvania service area

Thinking about the care you’ll need may help you know which D-SNP could be right for you. You can also think about what’s most important to you, like out-of-pocket costs and benefits and programs.

Diamond D-SNP

You may consider a Diamond D-SNP if you live within our 62 Pennsylvania service area counties. In addition to not having to pay a monthly cost for your D-SNP, you’ll get prescription drug benefits and other helpful assistance programs.

Other plan highlights include zero-dollar costs for:

• Preventive screenings
  
• Primary care provider office visits
• Emergency care
  

You’ll find coverage – and out-of-pocket cost – specifics in your Evidence of Coverage (EOC) booklet.

SSBCI eligibility requirements 

To qualify for the Special Supplemental Benefits for the Chronically Ill (SSBCI), you must first meet specific eligibility criteria. Eligibility is determined by meeting all three of the following:

• You must be diagnosed with one or more of the qualifying chronic conditions below.
• You must have a high risk for hospitalization and/or adverse health outcomes.
• You must actively participate in the plan’s Care Management Program.

Please note: A diagnosis of one of the qualifying chronic conditions alone does not guarantee eligibility. All three criteria listed above must be met.  How to Qualify for SSBCI Benefits After Meeting Eligibility Criteria:  Once you meet the eligibility criteria, qualification for SSBCI benefits can be determined in one of two ways: 

1. Review of Historical Information: The Plan will review your historical claims and medical records to determine if you meet the requirements for SSBCI benefits based on your documented history.  

2. Provider Attestation: If additional information is needed to confirm your eligibility and qualification, your doctor will be required to complete a Provider Attestation Form on your behalf, indicating that you meet these requirements.    

Accessing the Provider Attestation Form:  
The Provider Attestation Form is available in your welcome kit, enrollment kit, and can also be found here.    

Effective Date:
Your eligibility becomes effective on the date the Health Plan determines that you meet all three eligibility criteria described above.  

Qualifying Chronic Condition

• Autoimmune disorders
• Cancer
• Cardiovascular disorders
• Chronic alcohol use disorder and other substance use disorders (SUDs)
• Chronic and disabling mental health conditions
• Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell
• Chronic gastrointestinal disease
• Chronic heart failure
• Chronic kidney disease (CKD)
• Chronic lung disorders
• Conditions associated with cognitive impairment
• Conditions with functional challenges
• Dementia
• Diabetes mellitus
• HIV/AIDS
• Immunodeficiency and Immunosuppressive disorders
• Neurologic disorders
• Overweight, obesity, and metabolic syndrome
• Post-organ transplantation
• Severe hematologic disorders
• Stroke
• Therapy services required for individuals to maintain or retain functioning

How Your D-SNP Works

When you’re covered by a D-SNP, the way you’ll get care is like getting care with a Health Maintenance Organization (HMO) health plan.

Visiting Network Doctors

When you have a D-SNP, you’ll select your primary care provider (PCP) from our Highmark Wholecare provider network for your routine care.

Coordinating Your Services 

Your PCP will oversee the rest of your care and get approval for you to work with other providers if needed.

Paying For Prescriptions

In most cases you’ll use a network pharmacy to ensure your prescriptions are covered.