Special Needs Plans (SNP) is a type of Medicare Advantage plan that coordinates care benefits specifically to suit those with certain special needs. It is designed to offer coverage to those who need it the most. Medicare Advantage or Part C of Medicare is a health care plan provided by private insurance companies which offer at least the same coverage as Original Medicare but often gives additional benefits. The beneficiaries of Special needs plans are institutionalized, dual eligible for Medicare and Medicaid, or suffering from a severe or disabling chronic medical condition.
Special Needs Plans require that you get your care from providers within the network. The only exceptions from this are in the case of emergency care, or if you have End-Stage Renal Disease, are out of state, and need dialysis. All Special Needs Plans provide prescription drug coverage (Part D). Many SNPs require that you have a primary care doctor or care coordinator. You have to receive a referral to see a specialist, except in cases where the service is covered as preventative, such as with yearly screening mammograms or pap tests performed in-network.
Medicare Special Needs Plans Coverage
Special Needs Plans give coverage for all Medicare services in one bundle. It gives beneficiaries Part A coverage for inpatient services, Part B coverage for outpatient services, and Part D coverage for prescription drug coverage. Basically, what is offered through Medicare Advantage is also offered in the Special Needs plan, with one additional benefit. Special Needs Plans offer extra services based on the beneficiary`s unique healthcare situation and needs. That benefits might include an allowance for spending extra days admitted in the hospital, a care management specialist, or other needed social services.
Types of SNP
There are 3 types of Special Needs plans, each offering different benefits regarding your healthcare situation and needs. They are Chronic Condition Special Needs Plan, Dual Eligible Special Needs Plan, and Institutional Special Needs Plan.
Chronic Condition Special Needs Plan
A majority of Medicare beneficiaries have two or more chronic conditions. However, these plans are restricted to specific severe or disabling chronic conditions. These individuals have comorbid or medically complex chronic conditions that are disabling or life-threatening; this group of people also has a high risk of hospitalization or adverse health outcomes and require specialized care. Some of these conditions include cancer, dementia, End-Stage Renal Disease, HIV/AIDS, and amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease). There are fifteen conditions, some functioning as categories with multiple diagnoses such as cardiovascular disorders and chronic lung disorders.
If you have one of the following diagnoses or conditions, you are eligible for Chronic Condition SNP:
- chronic heart faillure
- End-stage Renal disease
- diabetes type 2
- End-stage Liver disease
- neurological issues
- autoimmune disorders
- mental health conditions
- cardiovascular disease
- lung disease
- hematologic disorders
- substance use disorder
To enroll in the chronic disease program, you will have to provide a note from your doctor stating that you have one of the covered conditions. You will probably be required to submit to a medical underwriting process.
Dual Eligible SNP
Beneficiaries of Dual Eligible Special Needs Plan are dually eligible for Medicare and Medicaid. There are multiple categories of Medicare eligibility, ranging from full Medicare eligibility to receiving aid as a Qualified Medicare Beneficiary. These plans have optional Medicare zero-dollar cost sharing.
For the dual eligibility plan enrollment, you will have to prove that you have Medicaid by showing a card or letter from Medicaid.
Institutional Special Needs Plan
Institutional Special Needs Plans are for individuals who have lived in a long-term skilled nursing facility, long-term care nursing facility, a combined skilled nursing facility/nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility. They have to stay in the facility for at least 90 days to enroll in this plan. The Institutional Special Needs Plan will confirm that you are receiving an institutional level of care, as assessed by an independent, impartial party in order to enroll you.
For the Institutional Special Needs plan enrollment, you must live for at least 90 days in a long-term care facility covered by the program, or meet your state’s requirements for needing higher level care.
Special Needs Plans Enrollment
You can enroll in Special Needs Plans during the Medicare Advantage Open enrollment period or during the Special Enrollment period. The Special Enrollment period is for those who have changes in their health condition, place of living, employment, or change of plans owned. Special enrollment is also for those who have both Medicaid and Medicare.
Individuals with disabling chronic diseases, or those with a need for a higher level of care, can enroll in Special Needs Plans at any time.
To be eligible to enroll in Special Needs Plan you need to already be enrolled in Original Medicare – Part A and Part B, or in some Medicare Advantage (Part C) plan.