Benzinga Explains: A Guide for Medicare Special Needs Plans

Medicare Special Needs Plans (SNPs) are a kind of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs only let people who have certain diseases or medical conditions join. SNPs customize their benefits, provider choices and prescription plans to meet the needs of their members. 

Medicare SNPs can help you manage your different services and providers because they bundle all your health care services into a single plan. They can make it easier for you to do what your doctor tells you to do with your diet and medications.

What are Medicare Special Needs Plans?

Medicare SNPs are designed for people with chronic or disabling conditions including autoimmune disorders, cancer, diabetes, chronic heart failure and cardiovascular disorders, to name a few. 

Medicare SNPs cover the same Medicare services that all Medicare Advantage plans must cover. Medicare SNPs may also cover extra services, like extra days in the hospital, that are designed for the special groups they serve.

Three different types of SNPs are available each with specific costs, coverage specifics and providers: 

Chronic Condition SNP (C-SNP): The 15 SNP-specific chronic conditions are covered under C-SNP: 

1. Chronic alcohol and other drug dependence
2. Autoimmune disorders
3. Cancer
4. Cardiovascular disorders
5. Chronic heart failure
6. Dementia
7. Diabetes mellitus
8. End-stage liver disease
9. End-stage renal disease requiring dialysis
10. Severe hematologic disorders
11. HIV/AIDS
12. Chronic lung disorders
13. Chronic and disabling mental health conditions
14. Neurologic disorders
15. Stroke

Institutional SNP (I-SNP): Institutional SNPs are designed for individuals in a long-term care (LTC) skilled nursing facility (SNF), LTC nursing home, SNF/NF, ICF/IDD or psychiatric hospital. You must need institutionalized care for 90 days or more to qualify for an I-SNP.

If you live at home but need institutional-level care, you may qualify for an Institutional Equivalent Special Needs Plan (IE-SNP).

I-SNP costs range. Medicare Part B premiums, copays, deductibles and coinsurance may still be due.

Dual Eligible SNP (D-SNP): Health insurance with dual special needs is available. It's for dual Medicaid/Medicare recipients. Being "dual-eligible" means you can have Medicaid and Medicare simultaneously.

Dual special needs plans provide extra aid because of income, limitations, age or health. Medicare Advantage Dual SNPs are also abbreviated as D-SNPs. The names are synonymous.

Dual special needs plans operate with Medicaid. You'll keep your Medicaid plan and benefits with added benefits and features, all for zero premium. 

States may have different qualifying categories, so eligibility requirements may vary.

When can you Join Medicare Special Needs Plans?

You can switch Medicare SNPs at any time. If you're newly eligible for Medicare, you can join any Medicare SNP during your Initial Enrollment Period, which starts three months before your 65th birthday and ends three months after.

You can join if you're disabled three months before or after your 25th month.

You can join any Medicare SNP you qualify for between October 15 and December 7, with coverage starting January 1.

If you have Medicare and develop certain severe or disabling conditions or enter a nursing home, you can join a Medicare SNP tailored to serve persons with those conditions at any time, but this Special Enrollment Period expires once you join a plan.

If you move out of your Medicare SNP's service region, you can swap plans or be restored to your Original Medicare.

When your Medicare SNP leaves Medicare, you can swap plans.

Who can a Join Medicare Special Needs Plans?

People who fall into one of the following categories are qualified to enroll in a Special Needs Plan (SNP): 

1) people who reside in specific institutions (like nursing homes) or who reside in the community but require nursing care at home;

2) people who are qualified for both Medicare and Medicaid; or

3) people who have particular chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure or dementia).

Plans may further restrict participation to individuals who have either a single chronic ailment or a group of chronic conditions that are tied to one another. 

Special Needs Plan Appeals

You can appeal these Medicare or Medicare plan coverage or payment decision denials:

• Request for a Medicare-covered health care service, supply, equipment or prescription.
• Request to pay for a medical service, product, item, or drug.
• Request to change a health care service, item or drug's price.
• If Medicare or your plan stops paying for a service, supply, item or drug you need.
• A drug management program's at-risk determination that limits access to opioids and benzodiazepines.

Your Medicare Special Needs Plan must explain to you how to appeal in writing. The plan will reconsider its judgment once you appeal. If your appeal is denied, an independent organization reviews it. It works for Medicare, not the plan.

If you appeal, ask your doctor, health care provider or supplier for information. Consult your plan's literature or call for information about appeals.

Plan contact info is usually on your membership card. Or, see your plan's contact info. There are five stages of appeals. If you disagree with a ruling, you can usually appeal. At each step, the decision letter will tell you how to appeal.

Benzinga’s Medicare Special Needs Plan Checklist

Medicare SNP plans provide benefits for Medicare members with special needs qualifications. Here is a handy checklist of things you should know about Medicare SNP plans.

Where to get healthcare with a Medicare SNP: Some SNPs will pay for services provided outside of their network, while others will not. Check with the provider to see if the plan covers services that are received outside of the network and, if so, how the additional coverage will affect your payments. Most Medicare SNPs have medical professionals that specialize in the illnesses or disorders that its members experience.

Where to get prescriptions with a Medicare SNP: You will receive the same prescription coverage with an SNP as regular Medicare. All SNPs must provide Medicare drug coverage (Part D).

Choosing a primary care doctor while with a Medicare SNP: Yes, in most cases to participate in SNPs, you will need to have a primary care doctor. Alternately, the plan can mandate that you work with a care coordinator who will assist you with your medical needs.

Referrals to see a specialist with an SNP: To consult with a specialist in SNPs, you will almost always need a referral from your primary care physician. Some types of services do not need a recommendation, including the following:

• Mammograms for breast cancer screening once a year

• A Pap test and pelvic exam covered by the network (covered at least every other year)

Compare Medicare Special Needs Plans

Medicare SNP coverage requires a reputable company with competitive rates. Benzinga compared the finest Medicare insurance carriers to help you choose.

Frequently Asked Questions