Medicare Advantage Special Needs Plans

checkmark Fact checked Reviewed by: Leron Moore, Medicare consultant - Updated: Aug 14, 2021

 

A Medicare Special Needs Plan is a type of Medicare Advantage Plan that can provide complete health care coverage – but not everyone can qualify.

What you should know

  • 1 An SNP provides hospital, medical, and prescription drug coverage.
  • 2 You’ll need to meet specific eligibility requirements, including living in a nursing home, dual eligibility for Medicare and Medicaid, or a specific chronic illness.
  • 3 Some SNPs offer coverage tailored to your condition.
  • 4 Coverage is generally limited to care from providers within the SNP network.

You may be eligible for a Medicare Advantage Special Needs Plan (SNP) if you have a specific disease or meet other criteria. These plans offer benefits, providers, and prescription drug coverage that meets the needs of your condition. Read on to learn if you may qualify, how to get coverage, and everything else you need to know when you get an SNP.

What are Medicare Advantage Special Needs Plans?

An SNP is a Medicare Advantage Plan designed for individuals who need targeted care and meet the criteria for a specific SNP. SNPs, like other Medicare Advantage Plans, are Medicare coverage offered by insurance companies.

What SNPs cover

SNPs are a complete plan, meaning you shouldn’t need additional Medicare plans to get the coverage you need. The coverage for an SNP includes Original Medicare and Medicare Advantage benefits, so you’ll get hospital, medical, and prescription drug coverage. In some cases, an SNP may offer extra services tailored to serve special groups. For example, the plan may cover extra days added to an inpatient stay.

How do I qualify for a Medicare Advantage Special Needs Plan?

To be eligible for an SNP, you must have Original Medicare Parts A and B and meet qualifications for an SNP type. There are three Special Needs Plans tailored to meet your needs whether you’re institutionalized, dual eligible, or have a chronic illness:

  • Institutional Special Needs Plan (I-SNP): You’re eligible if you live in an institution for care. That includes if you’ve had or expect to need services provided by a long-term care home, skilled nursing facility, or inpatient psychiatric facility for at least 90 days. You don’t have to receive long-term care for 90 days before enrollment as long as you will likely receive long-term care for at least 90 days.
  • Dual Eligible Special Needs Plan (D-SNP): You can qualify for a DSNP if you meet the qualifications to have both Medicare and Medicaid. Generally, that requires a low income, and you must be 65 or older or have a qualifying disability.
  • Chronic Condition Special Needs Plan (C-SNP): This plan is available if you have a specific severe or disabling chronic condition. A letter from your physician may be required to enroll in a CSNP. Qualifying conditions include:
    • Autoimmune disorders
    • Cancer (excluding pre-cancer conditions)
    • Cardiovascular disorders
    • Chronic alcohol and other dependence
    • Chronic and disabling mental health conditions
    • Chronic heart failure
    • Chronic lung disorders
    • Dementia
    • Diabetes mellitus
    • End-stage liver disease
    • End-Stage Renal Disease (ESRD)
    • HIV/AIDSNeed for dialysis (any mode of dialysis)
    • Neurologic disorders
    • Permanent kidney failure that requires a regular course of dialysis or a kidney transplant.
    • Severe hematologic disorders
    • Stroke

Medicare SNPs may be a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), influencing which providers are covered and whether you can use out-of-network coverage.

What are the benefits of Medicare Advantage Special Needs Plans?

Medicare Advantage Plans, including SNPs, offer many benefits beyond Original Medicare.

Original Medicare is limited to:

  • Hospitalization (Part A)
  • Primary care coverage (Part B)
  • Optional prescription drug plan (Part D) at an additional cost

An SNP will offer several benefits to take advantage of to either bring you back to good health or maintain your health:

  • Original Medicare benefits hospital and primary care)
  • Prescription drug coverage
  • Vision
  • Dental
  • Hearing

Some SNPs may offer:

  • Emergent and non-emergent transportation
  • Meals after a major surgery
  • A care manager or care coordinator assigned to help coordinate your care

How much do Medicare Advantage Special Needs Plans cost?

Medicare Advantage SNPs are cost effective. You may pay a small monthly payment, but in most cases, the premium is $0. Typically, the cost share is fairly low as well.

For example, to see your primary care provider, you would pay $0 for each visit. Plans such as a D-SNP with both Medicare and Medicaid may offer $0 specialist visits. Depending on the SNP, you will see enriched benefits and low-cost share obligations in specific areas to cater to the eligible individuals.

How do I enroll in a Medicare Advantage special needs plan?

There are several ways to enroll in an SNP. If you are eligible for Original Medicare and meet the SNP criteria, you can enroll at any time. Also, you have to meet the criteria of the SNP that you are applying for.

Before joining a Medicare SNP, research to ensure the plan is right for you, then shop again every year for a plan that suits your needs. If you need help, take advantage of resources that can assist you in the process of choosing a plan and enrolling, such as a licensed health insurance agent or local Area Agency on Aging.

You have multiple options for enrollment:

  • Phone: You can apply over the phone by calling Medicare at (1-800-633-4227), or you can also contact the plan of your choice directly.
  • Online: You have the option of enrolling online through a third-party website or the plan’s website.
  • Insurance agent: If you decide to recruit an agent for assistance, you will enroll either by paper or electronic application.

Before making a decision, ensure you’re well informed and all of your questions get answered.

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Contributing Expert:

Leron Moore, Medicare consultant

Leron Moore has guided Medicare beneficiaries and their families as a Medicare professional for nearly 15 years. First as a Medicare provider enrollment specialist, and now a Medicare account executive, Moore works directly with Medicare beneficiaries to ensure they understand Medicare and Medicare Advantage Plans.