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Medicare Special Needs Plans

Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage plan that provides organized care to beneficiaries with specific needs. Like all Medicare Advantage plans, SNPs will have a network, typically either an HMO or a PPO. 

SNPs restrict their membership to beneficiaries who have certain illnesses, chronic conditions, or circumstances. The plans must contain all of the same services as Original Medicare. 

However, Special Needs Plans adjust their network, plan benefits, and drug formulary to accommodate the individuals’ needs. All Special Needs Plans have a built-in Part D drug plan as well. 

There are different types of Special Needs Plans, and they all work in different ways.

Chronic Illness Special Needs Plan

A SNP based on health conditions is designed to provide outstanding support for those who have a chronic illness. For instance, the SNP might grant access to a network of providers who are experts at treating these specific illnesses.

These providers collaborate to organize your care. The plan often nominates a care coordinator that will help you access community resources, manage your health condition, and follow your provider’s orders. Also, the plan’s built in drug formulary will likely offer a list of drugs that treat this specific health condition. 

To qualify for a Chronic Illness Special Needs Plan, you must have one or more of the following health conditions:

  • Cancer
  • Diabetes
  • HIV or AIDS
  • Neurologic conditions
  • Chronic mental illness
  • Chronic lung disorders
  • Hematologic disorders
  • Autoimmune disorders
  • ESRD requiring dialysis
  • Alzheimer’s or Dementia
  • Cardiovascular disease, stroke, or chronic heart failure

To join this plan, ask your agent for a chronic condition form that will verify your eligibility. Have your doctor complete this form and return it. 

Chronic Illness SNPs differ by county. Insurance carriers get to decide where they’ll offer certain plans. It may or may not be hard to find a SNP in your area that specializes in the condition you have. Check with your Medicare insurance agent to see what’s available. 

Institutional Special Needs Plan (ISNP)

Medicare beneficiaries who reside in an institution, like an assisted living center or nursing home, could qualify for an Institutional SNP. 

Institutional SNPs are like the chronic illness SNP but they instead concentrate on the provision of organized care to a person who is no longer living alone. The beneficiary has to be expected to live in the institution for a minimum of 90 days.

Dual Eligible Special Needs Plan (DSNP)

Some beneficiaries also qualify for Medicaid, which is a health insurance program for those with low incomes. When you qualify for Medicare and Medicaid, you can maintain your Original Medicare and have Medicaid operate as your secondary coverage, or you can sign up for a Dual Eligible Special Needs Plan. 

The costs to join will be mostly covered for you. Expect to spend little (or nothing) on copays, deductibles, and coinsurance for Part A and Part B services that the plan provides. Since Medicaid pays any premium for you, many DSNPs have a $0 premium.  

DSNPs frequently offer these benefits, too:

  • Gym memberships
  • Routine dental, vision, and hearing benefits 
  • Quarterly benefits for over the counter products
  • Transportation to and from doctor’s appointments or trips to the pharmacy

Your Medicare agent or your plan will have to validate your eligibility for Medicaid before enrolling you in the Dual Eligible Special Needs Plan.

Enrolling in a Medicare Special Needs Plan

To qualify for enrollment, you must be enrolled in both Medicare Parts A and B and live in the plan’s service area. You’ll keep paying Social Security for your Part B premium the whole time that you’re enrolled in the plan (unless Medicaid covers this is for you). You’ll also pay a monthly premium that the plan charges for the SNP, plus the deductibles, copays, and coinsurance. 

Sometimes these plans are offered without a monthly premium.

You can enroll in a SNP during your Initial Enrollment Period for Medicare or during any Fall Annual Election Period. 

In certain situations, some folks may also qualify for Special Enrollment Periods during the year. These situations include:

  • Qualifying for Medicaid
  • Moving out of state or outside of your current plan’s service area
  • Moving into, living in, or moving out of an institution
  • Being diagnosed with a chronic or severe condition that makes you qualified for a Chronic Condition SNP

If you lose your eligibility for a Special Needs Plan, you’ll have a grace period that allows you to leave the plan and join another — or return to Original Medicare.

Call Us for Questions About Special Needs Plans

Cornerstone Senior Advisors works with a multitude of Medicare Advantage Special Needs Plans. We want to help you find the right SNP for your situation. For questions, or to set up an appointment, call (316) 260-3331 today.