Medicare Special Needs Plans (SNPs) are type of Medicare Advantage plan that provides coordinated care to beneficiaries with specific needs or situation. Like all Advantage plans, Special Needs Plans will have a network, usually either an HMO or a PPO.
These SNPs limit their membership to beneficiaries who have specific illnesses, chronic conditions, or circumstances such as being eligible for both Medicare and Medicaid. The plans must include all of the same services as Original Medicare Parts A and B.
However, Special Needs Plans tailor their plan benefits, network and drug formulary to meet the needs of individuals who have these specific health conditions or circumstances. All Special Needs Plan include a built-in Part D drug plan.
Let’s review some of the types of Special Needs Plans and how they work:
Chronic Illness Special Needs Plan
A Medicare Advantage Special Needs Plan based on health conditions is a plan that is specifically designed to provide excellent support for individuals with a chronic illness. For example, the SNP might offer provide access to a group of providers who specialize in treating these specific illnesses.
These providers work together to coordinate your care. The plan will often assign a care coordinator or case manager to assist you with keeping healthy, managing your health condition and following your provider’s orders. He or she might also help you with accessing community resources or getting the right prescriptions in a timely manner.
The drug formulary that is built into the plan is also likely to offer a robust list of drugs that treat this particular health condition.
To qualify for a chronic illness SNP, you must have one or more of health conditions listed below:
- Autoimmune disorders
- Cardiovascular disease, stroke, or chronic heart failure
- Alzheimer’s or Dementia
- ESRD requiring dialysis
- Hematologic disorders
- HIV or AIDS
- Chronic lung disorders (like COPD)
- Chronic or disabling mental illness
- Neurologic conditions
In order for you to join a Chronic Illness SNP, your doctor will have to complete a chronic condition verification form at the time of your enrollment. Your agent will provide you with the form and your doctor can complete this form and return it to verify your eligibility.
Chronic Illness SNPs vary by county. Insurance companies get to choose where they will offer certain plan designs, so you may or may not be able to find a SNP in your area that specializes in the condition that you have. Check with your Medicare insurance broker to see what is offered.
Institutional Special Needs Plan (ISNP)
Medicare beneficiaries who live in an institution, such as an assisted living center, nursing home or memory care center) may qualify for an Institutional SNP.
These plans are similar to the chronic illness SNP but instead focus on dealing with the provision of coordinated care to someone who is no longer living independently. The beneficiary must be expected to live in the institution for at least 90 days.
Dual Eligible Special Needs Plan (DSNP)
Some Medicare beneficiaries also qualify for Medicaid. Medicaid is a federal and state health insurance program for people with low incomes.
When you qualify for both, you can keep your Original Medicare and have Medicaid function as your secondary coverage, or you can enroll in a Dual Eligible Special Needs Plan.
People with full Medicaid can expect to spend little to nothing on deductibles, copays, and coinsurance for Part A and B services provided by the plan. Many plans have a $0 premium because Medicaid pays any plan premium for you. People with partial Medicaid may have to pay some cost-sharing.
Dual Special Needs Plans often also offer rich ancillary benefits. These might include:
- Quarterly benefits for over the counter products
- Telemedicine services
- Transportation to and from doctor appointments or trips to the pharmacy
- Routine dental, vision and hearing benefits
- Gym memberships
The plan or your agent will need to verify your eligibility for Medicaid before they can enroll you into the DSNP plan.
Enrolling in a SNP
To qualify for enrollment into a Special Needs Plan, you must live in the plan’s service area and be enrolled in both Medicare Part’s A and B. You will continue to pay your Part B premium to Social Security the entire time that you are enrolled in the plan (unless this is covered for you by Medicaid.)
You will also pay any monthly premium that the plan itself charges for the SNP. Finally you will pay the regular cost-sharing expenses, such as deductibles, copays, and coinsurance. These amounts can be found in the plan’s Summary of Benefits, which you should review before joining the plan.
You can enroll in a Medicare Advantage SNP during your Initial Enrollment Period for Medicare or during any Medicare Fall Annual Election Period. Some people may also qualify for Special Enrollment Periods during the year in certain situations. These include:
- Moving outside of your current plan’s service area
- Qualifying for Medicaid
- Moving into, living in, or moving out of an institution
- Being diagnosed with a severe or chronic condition that qualifies you for a Chronic condition SNP
If you lose your eligibility for a SNP, you will have a grace period within which you can leave the plan and join another plan or return to Original Medicare.
Have Questions about Medicare Special Needs Plans?
Our agency works with a number of Medicare Advantage Special Needs Plans. Give our team a call to see if we can help you find the right SNP for you.