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Medicare Advantage Special Needs Plans

Table of Contents

Summary: Medicare Advantage Special Needs Plans provide tailored healthcare coverage for individuals with severe chronic conditions and those receiving Medicaid benefits. Learn about the three types of Special Needs Plans, what they cover, and who is eligible to enroll. Estimated Read Time: 4 min

What are Medicare Special Needs Plans?

Medicare Special Needs Plans are Medicare Advantage plans that provide healthcare coverage and benefits to people with certain diseases, certain healthcare needs, or people receiving Medicaid benefits. These plans specially tailor their benefits, provider choices, and drug coverage to meet the needs of individuals with complex healthcare needs.

Like other Medicare Advantage Plans, Special Needs Plans are offered by private insurance companies. Therefore, the availability and costs of Medicare SNPs will vary by location and carrier. Even though carrier and plans may vary, all SNPs are required to provide Medicare Part D prescription drug coverage. They must also abide by the rules set by Medicare for Medicare Advantage plans.

What are the Three Types of Special Needs Plans?

Since Medicare Special Needs Plans are tailored to meet the needs of different groups, there are three different types of plans available.

Three Types of Medicare Advantage Special Needs Plans

A Dual Eligible Special Needs Plan (D-SNP) is for individuals who are eligible for both Medicare and Medicaid. These plans help coordinate your Medicare and Medicaid benefits by contracting with your state’s Medicaid program.

A Chronic Condition Special Needs Plan (C-SNP) is a plan that is tailored to meet the needs of individuals with severe chronic conditions such as cancer. These plans allow for coordinating care among primary health physicians, medical specialists, inpatient and outpatient facilities, and more. A C-SNP helps ease the burden of those suffering from chronic conditions by providing coverage to a wide range of services and providers.

An Institutional Special Needs Plan (I-SNP) provides coverage for seniors who live in, or are expected to live in, a facility such as a nursing home or rehabilitation hospital.

Medicare Special Needs Plans Costs and Coverage

Medicare Advantage Special Needs Plans vary in costs and coverage from plan to plan and provider to provider. Though these plans differ, there are some important things to keep in mind regarding SNPs:

  • All SPNs must include hospital coverage (Medicare Part A), outpatient coverage (Medicare Part B), and prescription drug coverage (Medicare Part D)
  • Some SPNs charge a monthly premium, which you would have to pay in addition to your Medicare Part B premium.
  • All Special Needs Plans use a care coordinator that works with you to develop a care plan

Medicare SPNs are either HMO or PPO plan types, which means some plans will require you to use physicians within their network, and some plans will allow you to go outside of the network at an increased cost.

It’s important to always review a plan carefully before enrolling to ensure you understand your costs and network requirements.

Who Qualifies for Medicare Special Needs Plans?

Unlike other Medicare Advantage plans, Special Needs Plans have stricter eligibility requirements you must meet to enroll. To enroll in a Special Needs Plan, you must have Original Medicare (Parts A and B), live in a plan’s service area, and meet the requirements for the SPN if it is offered in the area you reside in. Each type of Special Needs Plan has its own eligibility requirements:

Dual Eligible Special Needs Plan Eligibility

To be eligible for a Dual Eligible SNP, you must be eligible for both Medicare and medical assistance through your state’s Medicaid program. Depending on your level of Medicaid, certain Dual Eligible plans may not be available. When researching Special Needs Plans, you can check to see if the plan accepts your level of Medicaid in the plan’s Summary of Benefits.

Chronic Condition Special Needs Plan Eligibility

Medicare enrollees who suffer from severe and/or disabling chronic conditions may be eligible for a Chronic Condition SNP. The Centers for Medicare & Medicaid Services has approved a list of 15 chronic conditions that would qualify for a C-SNP. These conditions include cancer, autoimmune diseases such as rheumatoid arthritis, stroke, dementia, HIV/AIDS, and more.

Institutional Special Needs Plan Eligibility

If you live or are expecting to live in an institution such as a nursing home, you may be eligible for an Institutional SPN. These plans are also available for those who live at home but require an institutional level of care. As a requirement to enroll, you must provide proof that you will be living in, or are expecting to live in a facility for at least 90 days. Eligible institutions include nursing homes, rehabilitation hospitals, skilled nursing facilities, psychiatric hospitals, and more.

Not all types of Special Needs Plans are available in all areas.

How to Enroll in a Medicare Advantage SNP (Special Needs Plan)

When you have complex and extensive healthcare needs, choosing a Medicare plan can be challenging. If you qualify for a Medicare Special Needs Plan and want to explore your coverage options, give us a call. Our licensed insurance agents can provide a side-by-side comparison of plans available in your area.

We are dedicated to finding the right plan to fulfill your healthcare needs. If you don’t think you qualify for a Special Needs Plan, we can walk you through the process of finding other coverage that will work for your needs. Our agents work hard to save you time and money on your Medicare coverage so you can focus on your health.

Not available for a phone call? No problem! You can begin comparing your Medicare coverage options by filling out our online rates form.

Sources

Special Needs Plans (SNP), Medicare. Accessed July 2023

https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/SNP

Special Needs Plans, Centers for Medicare & Medicaid Services. Accessed July 2023

https://www.cms.gov/medicare/health-plans/specialneedsplans

Allison Auvil

Allison Auvil

Content Strategist
Allison Auvil is a Content Strategist at Elite Insurance Partners. With a bachelor’s degree in visual arts, Allison brings a creative perspective to her writing. She has been involved in content writing and editing for the past five years. The combination of an extensive Medicare101 training program and daily thorough research has made Allison a Medicare Guru. A detail-oriented writer, Allison is focused on writing pieces that are accurate, informative, and easy to read. She begins her writing process with meticulous research and note taking. Once her data is compiled, Allison enjoys the challenge of taking complex data and information and creating articles that are easy to understand.
Ashlee Zareczny

Ashlee Zareczny

Compliance Supervisor and Licensed Medicare Agent
Ashlee Zareczny is the Compliance Supervisor for ApplyforMedicare. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.
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