Medicare Special Needs Plans

Key Points

  • Medicare Special Needs Plans (SNPs) belong to the category of Medicare Advantage plans.

  • SNPs focus on coordinating care for beneficiaries with specific needs or situations.

  • Chronic Illness SNPs, Institutional SNPs, and Dual Eligible SNPs are some of the variations available.

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Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage plan specifically designed to provide coordinated care for individuals with certain health conditions or unique circumstances. Like other Medicare Advantage plans, SNPs typically operate within a network, most commonly structured as an HMO or PPO.

Enrollment in an SNP is limited to those who meet specific criteria—such as having a qualifying chronic illness, living in an institutional setting, or being eligible for both Medicare and Medicaid. These plans are required to cover all benefits offered under Original Medicare Parts A and B.

What sets SNPs apart is their ability to tailor benefits, provider networks, and drug formularies to better serve the specialized needs of their members. Additionally, all Special Needs Plans include a built-in Medicare Part D prescription drug plan.

Let’s take a closer look at the different types of SNPs and how each one works:

Special Needs Plan for Chronic Illness

A Medicare Advantage Special Needs Plan (SNP) designed for chronic conditions is specifically created to provide enhanced support for individuals managing long-term health issues. These plans often include access to a network of providers who specialize in treating the targeted condition, working together to ensure coordinated, personalized care.

Many chronic condition SNPs assign a care coordinator or case manager to help you manage your health, follow treatment plans, access prescriptions, and connect with community resources.

These plans typically feature a drug formulary tailored to include medications commonly used to treat the specific chronic condition.

To qualify for a Chronic Condition SNP (C-SNP), you must be diagnosed with one or more of the following conditions:

• Autoimmune disorders

• Cancer

• Cardiovascular disease, stroke, or chronic heart failure

• Alzheimer’s disease or dementia

• Diabetes

• End-Stage Renal Disease (ESRD) requiring dialysis

• Hematologic disorders

• HIV/AIDS

• Chronic lung conditions (e.g., COPD)

• Chronic or disabling mental illness

• Neurologic disorders

To enroll, your doctor must complete a chronic condition verification form, which your licensed agent will provide. Once completed, your doctor can return the form to confirm your eligibility.

Since plan availability varies by county, be sure to consult a licensed Medicare insurance broker to explore which Chronic Condition SNPs are offered in your area.

Institutional Special Needs Plan (ISNP)

Medicare beneficiaries who live in an institutional setting, such as a nursing home, assisted living facility, or memory care center, may qualify for an Institutional Special Needs Plan (I-SNP).

Much like Chronic Condition SNPs, Institutional SNPs focus on delivering coordinated care tailored to individuals who are no longer living independently. To be eligible, the beneficiary must be expected to reside in the facility for at least 90 days.

Dual Eligible Special Needs Plan (DSNP)

Some Medicare beneficiaries also qualify for Medicaid, a state and federally funded program that provides health coverage for individuals with low income.

If you’re eligible for both programs, you have two options: you can keep Original Medicare with Medicaid as secondary coverage, or enroll in a Dual Eligible Special Needs Plan (D-SNP).

Beneficiaries with full Medicaid benefits typically pay little to nothing for deductibles, copays, and coinsurance related to Medicare Parts A and B. Many D-SNPs also have a $0 premium, as Medicaid covers the plan cost. Those with partial Medicaid may be responsible for some cost-sharing depending on their eligibility level.

Dual Special Needs Plans frequently provide comprehensive additional benefits, which may encompass:

Quarterly allowances for over-the-counter products

Telemedicine services

Transportation to and from medical appointments or pharmacy visits

Routine dental, vision, and hearing benefits

Gym memberships

Verification of Medicaid eligibility is essential for enrolling in a Dual Special Needs Plan, and this process can be facilitated by the plan or your agent.

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Joining a Special Needs Plan (SNP)

To enroll in a Special Needs Plan (SNP), you must live within the plan’s service area and be enrolled in both Medicare Part A and Part B. You’ll continue paying your Part B premium to Social Security, unless it’s covered by Medicaid.

In addition, you may be responsible for the monthly premium charged by the SNP, along with cost-sharing expenses such as deductibles, copays, and coinsurance. These details are outlined in the plan’s Summary of Benefits, which should be reviewed carefully before enrolling.

You can join a Medicare Advantage SNP during your Initial Enrollment Period or the Medicare Annual Election Period each fall. Certain life events may also qualify you for a Special Enrollment Period, such as:

1. Moving outside your current plan’s service area

2. Becoming eligible for Medicaid

3. Entering, residing in, or leaving an institution

4. Being diagnosed with a qualifying chronic or severe condition for a Chronic Condition SNP

If you lose eligibility for your SNP, you’ll be granted a grace period to switch to another plan or return to Original Medicare.

Do you have inquiries regarding Medicare Special Needs Plans?

Our agency collaborates with several Medicare Advantage Special Needs Plans. Reach out to our team to explore whether we can assist you in identifying the most suitable SNP for your needs.

Key Takeaways

  • To enroll in a Special Needs Plan (SNP), beneficiaries must meet the plan’s specific eligibility requirements.

  • Availability depends on your ZIP code, as not all insurance companies offer SNPs in every area.

  • Enrollment must occur during a qualifying election period, such as the Initial Enrollment Period, Annual Election Period, or a Special Enrollment Period, if eligible.

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