Medicare Special Needs Plans

Medicare Advantage Special Needs Plans are for beneficiaries that qualify for special eligibility criteria. Special Needs Plans offer the same Medicare services, including mandatory drug coverage. Beneficiaries usually people who require institutional care or nursing care at home, are considered dual-eligible for Medicare and Medicaid or who are suffering from a severe medical condition. There are three Special Needs Plans for unique health-care needs that give extended coverage based on their unique needs.

Three types of Special Needs Plans:

  • Chronic-Condition Special Needs Plans (C-SNP): Beneficiaries with specific severe or disabling single or multiple chronic conditions. Example: Cancer, chronic health failure, or HIV/AIDS.
  • Institutional Special Needs Plans (I-SNP): Institutional Care (such as a nursing home), or nursing care at home.
  • Dual-Eligible Special Needs Plans (D-SNP): Beneficiaries with both Medicare and Medicaid benefits ( “dual eligibles”).

Usually, each SNP focuses on limiting its membership to one of these groups or a subset of the group. This enables the plan to cater to the unique needs of people within that limited group. Therefore, plans create access to a network of specialists and treatment centers specializing in a specific medical condition that the group suffers from, have a drug formulary suited to this condition, run programs to manage healthcare issues.

To fully understand Special Needs Plans, we have listed a few common questions and answers to help.

What is the Eligibility Criteria to join a Special Needs Plan?

There are a few requirements that applicants have to meet to be eligible to apply for an SNP.

  • They need to have Medicare Part A and Part B which covers hospital and medical insurance respectively
  • They must reside in the plan’s service network
  • They need to meet one of these eligibility requirements:
    • Be suffering from a chronic condition that may include one or more of these – autoimmune diseases, cancer, HIV/AIDS, dementia, severe lung issues, stroke, chronic dependence on alcohol and so on. Some plans may also allow people who have End-Stage Renal Disease to enroll.
    • Be living in a nursing home or receiving similar care at home
    • Be eligible to receive both Medicare and Medicaid

When can a Person Enroll in a Special Needs Plan?

If a person becomes eligible for Medicare and fulfills all the requirements to apply for a Special Needs Plan in their area, they can apply to enroll in one during one of these periods.

Initial Enrollment Period – Typically, people are first eligible to apply during their Initial Enrollment Period that is seven months long. This period begins three months before their 65Th birthday and finishes three months after. In some cases, eligibility for Medicare can happen earlier if a person is receiving Social Security or Railroad Retirement Board disability benefits. If this is the case, the enrollment period begins three months before the 25th month of receiving benefits and extends to three months after.

Annual Election Period – Applicants can also apply for Special Needs Plans between October 15 and December 7 every year. This period allows for a person to enroll, change plans, or leave their plan if they wish to.

Special Election Period – A person can also join or make changes to their Special Needs Plan in special circumstances. These include:

  • If diagnosed with a severe medical illness that qualifies for the plan
  • If they decide to join, are currently residing in or choose to move away from a nursing home
  • If they are beneficiaries of Medicaid or become eligible for the same
  • If they move out of the area serviced by the plan
  • If their plan decides to end their contract with Medicare

For a person to stay with their plan, they need to continue to meet all the eligibility criteria that are required by each plan. If circumstances change, a beneficiary can use the Special Election Period to choose another Medicare Advantage Plan or go back to Original Medicare.

What are the Benefits of Enrolling in a Special Needs Plan?

They are tailored to offer hospital coverage, medical healthcare needs coverage and prescription drug coverage via Medicare Part A, Part B, and Part D, along with additional benefits to suit a particular medical condition

Certain plans have care coordinators to assist beneficiaries in managing their healthcare needs and following their treatment carefully

Some plans offer wellness programs that offer dietary help and other activities to help with a particular medical condition

Chronic-Condition Special Needs Plans help provide access to a healthcare network and prescription drugs that are suitable to treat a specific medical illness that their members may be suffering from

Dual eligible beneficiaries may have access to social services to coordinate their Medicare and Medicaid benefits

Can a Beneficiary visit Doctors Outside the Plan Network?

Typically, Special Needs Plans are created with their beneficiaries’ special needs in mind and include an extended network with specific specialists in the specific healthcare field. Many plans require that a beneficiary makes use of services available within the plan network. Exceptions in situations requiring emergency medical attention or if a person has End-Stage Renal Disease and needs dialysis outside the plan’s network.

Most SNPs require beneficiaries to have a primary care physician. Alternatively, in some cases, a care coordinator may be required to help enrollees to manage their healthcare needs.

Does a Special Needs Plan Require Referrals to see Specialists?

Very often, beneficiaries need to get referrals to visit a specialist. However, there are certain services like annual mammograms and pap tests/pelvic exams offered within the network that may not require referrals.

What is the Role of a Care Coordinator in a Special Needs Plan?

Certain plans have a care coordinator who helps to take care of the plan enrollee’s medical needs. They can get the right information for the beneficiary and help them to follow their doctor’s advice correctly. For example, if a person suffers from a particular ailment, a care coordinator can help by monitoring their vitals, making them eat healthy, ensuring they get adequate exercise, scheduling appointments, and tests and making sure they have the right medication. If a person has both Medicare and Medicaid, a care coordinator can educate them with more information on how their insurance works and help coordinate common resources and medical services for them.

How Much Does a Special Needs Plan Cost?

Most SNPs require beneficiaries to pay their Medicare Part B premium and a monthly SNP plan premium. Some plans require additional monthly premiums for drug coverage and extra benefits. Any cost-sharing expenses in the form of copayments, coinsurance, and deductibles also need to be paid if required by the plan.

If a person is a dual-eligible beneficiary, a majority of their costs may typically be covered. If a person doesn’t receive any help from the state in paying for Medicare, the costs for their Special Needs Plan will depend on the exact plan they choose and the frequency of healthcare services they need. Out-of-pocket costs can also differ depending on services used within and outside the plan network.

Since Special Needs Plans are Medicare Advantage programs offered by private insurance companies, the type of plans, plan offerings and costs can differ between companies and what they offer every year in every region. If you are looking for Special Needs Plans, check for options that can help you manage your specific health situation better and offer you medical services and benefits that are special to your condition.

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