Medicare Special Needs Plans (SNPs) are a unique type of Medicare Advantage plan designed to provide comprehensive and coordinated care to individuals with specific needs or circumstances. Similar to other Advantage plans, SNPs typically operate within a network, which can be either an HMO or a PPO.
SNPs specifically cater to beneficiaries who have particular illnesses, chronic conditions, or meet specific criteria such as being eligible for both Medicare and Medicaid. These plans are required to offer the same services as Original Medicare Parts A and B.
However, what sets Special Needs Plans apart is their ability to customize their benefits, network, and drug formulary to better suit the requirements of individuals with these specific health conditions or circumstances. Additionally, all Special Needs Plans include a built-in Part D drug plan to ensure comprehensive coverage.
Chronic Special Needs Plan
A Medicare Advantage Special Needs Plan tailored to health conditions is a specialized plan that aims to offer exceptional support to individuals with chronic illnesses. For instance, the SNP may grant access to a network of healthcare providers who specialize in treating these specific ailments.
These providers collaborate to ensure the coordination of your care. The plan often assigns a care coordinator or case manager to assist you in maintaining good health, managing your condition, and adhering to your provider’s instructions. They may also aid you in accessing community resources or obtaining the necessary prescriptions promptly.
Moreover, the plan’s drug formulary is likely to include an extensive list of medications that effectively 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
Cancer
Cardiovascular disease, stroke, or chronic heart failure
Alzheimer’s or Dementia
Diabetes
ESRD requiring dialysis
Hematologic disorders
HIV or AIDS
Chronic lung disorders (like COPD)
Chronic or disabling mental illness
Neurologic conditions
To qualify for SNP, your doctor must fill out a chronic condition verification form during your enrollment process. Your agent will supply you with the form, which your doctor can complete and return to confirm your eligibility.
The availability of Chronic Illness SNPs differs from county to county. Insurance companies have the freedom to decide which plan designs they will offer, so it is possible that you may not find a SNP in your area that specifically caters to your condition.
Institutional Special Needs Plan (ISNP)
Medicare recipients residing in an establishment, such as an assisted living facility, nursing home, or memory care center, may be eligible for an Institutional SNP. These particular plans share similarities with the chronic illness SNP, but their primary objective is to ensure the provision of coordinated care to individuals who are no longer able to live independently. It is a requirement for the beneficiary to anticipate residing in the institution for a minimum of 90 days.
Dual Eligible Special Needs Plan (DSNP)
Certain individuals who are eligible for Medicare may also meet the requirements for Medicaid. Medicaid, a health insurance program administered jointly by the federal government and individual states, is designed to assist individuals with limited incomes.
If you qualify for both Medicare and Medicaid, you have the option to retain your Original Medicare coverage while utilizing Medicaid as a secondary form of insurance. Alternatively, you can choose to enroll in a Dual Eligible Special Needs Plan.
Individuals who have full Medicaid coverage can anticipate minimal or no expenses for deductibles, copays, and coinsurance associated with Part A and B services provided by the plan. Many plans even offer a $0 premium since Medicaid covers the cost of the plan premium. However, individuals with partial Medicaid coverage may be required to contribute towards certain cost-sharing measures.
Dual Special Needs Plans frequently provide a wide range of additional benefits. These may include:
1. Quarterly allowances for purchasing over-the-counter products.
2. Access to telemedicine services.
3. Transportation assistance for doctor appointments or visits to the pharmacy.
4. Comprehensive coverage for routine dental, vision, and hearing needs.
5. Inclusion of gym memberships.
Enrolling in a SNP
In order to be eligible for a Special Needs Plan, you must reside within the plan’s service area and be enrolled in both Medicare Parts A and B. Your Part B premium will still need to be paid to Social Security for the duration of your enrollment in the plan (unless Medicaid covers this for you). Additionally, you will be responsible for any monthly premium charged by the plan itself. Furthermore, you will need to cover the standard cost-sharing expenses like deductibles, copays, and coinsurance. These details can be found in the plan’s Summary of Benefits, which you should carefully review before enrolling. You can sign up for a Medicare Advantage SNP during your Initial Enrollment Period for Medicare or during the Medicare Fall Annual Election Period. Some individuals may also qualify for Special Enrollment Periods during the year under specific circumstances. These circumstances include:
– Relocating outside of your current plan’s service area
– Meeting the requirements for Medicaid
– Moving into, residing in, or moving out of an institution
– Being diagnosed with a severe or chronic condition that makes you eligible for a Chronic condition SNP If you become ineligible for a SNP, there will be a grace period during which you can switch to another plan or return to Original Medicare.
Takeaways
Beneficiaries are required to fulfill the criteria of a particular SNP in order to register. Not all insurance providers provide SNPs, hence the options accessible to a beneficiary will be based on their zip code. Enrollment in a SNP is mandatory during a qualifying election period.
Mario Arce
I have been working with Medicare clients since 2016. I serve California members in San Bernardino & Riverside county.
