Medicare Advantage Special Needs Plans

Special Needs Plans are a very unique type of Medicare Advantage plan. They are only available to Medicare beneficiaries who have certain health issues. Also, individuals who are “dual-eligible,” meaning they are eligible for both Medicare and Medicaid, can enroll in a separate type of SNP.

Certain health issues can be complicated. SNPs were created to help simplify the treatment and financial coverage of those health issues. Medicare Advantage Special Needs Plans include all Medicare Part A, Part B, and Part D benefits. Also, these plans may include other services available to its beneficiaries depending on specific health status or quality of life. Special Needs Plans members usually have specialists whose responsibility is to focus on supporting their specific condition and offering them the appropriate health care coordination.

Types of Medicare Advantage SNPs

There are three types of Special Needs Plans. We’ll briefly discuss each one. If you find yourself fitting into one of the three categories, an SNP may be a good option for your healthcare coverage.

The three types of Special Needs Plans are:

  1. Chronic Condition SNP (C-SNP)
  2. Institutional SNP (I-SNP)
  3. Dual-Eligible SNP (D-SNP)

All three of these plans require a primary care physician and the doctor you choose will be your main health care provider. Your chosen doctor will then manage all your care which is a part of the Medicare Special Needs plan network in your area and act as a care coordinator.

With a Special Needs Plan, you don’t have to sign up for different plans to get coverage for health services you might need. This is what makes an SNP a much more convenient and comprehensive choice than the original Medicare plan or the standard Medicaid services.

Most Special Needs Plans fall into a Health Maintenance Organization (HMO).

Medicare Advantage SNP Benefits

Special Needs Plans are beneficial because of the unique coverage they provide. They are tailored for the individuals that qualify for each type of plan.

For instance, one SNP may include specific coverage for individuals with heart issues. An SNP for this health condition may have a large network of cardiologists, clinical case management programs, and a custom drug formulary.

Individuals who enroll in an SNP will enjoy the benefits and coverage of a plan that has been customized to their unique health conditions and treatment needs. An SNP plan will always include prescription drug coverage, which is not always the case with other Medicare Advantage plans.

Overall, there are many benefits to Special Needs Plans. Benefits may include:

  • Routine dental, vision, and hearing coverage
  • Transportation to doctor’s appointments
  • Prescription delivery
  • Medical alert device and installation
  • Telehealth visits
  • An allowance for over-the-counter products
  • Routine podiatry care
  • Incentives for completing preventive services

Medicare Advantage SNP Limitations

Like other Medicare Advantage plans, SNP plans offer the same coverage as Parts A and B of Original Medicare. However, since these plans are offered by private insurance companies, they will have their own costs, rules, and limitations. Limitations may include only receiving services from providers within the plan’s network.

This limitation will be lifted if an individual has a sudden illness that requires immediate attention and care in an emergency room setting. It also does not apply to individuals with ESRD who require dialysis treatment outside of the plan’s service area.

Otherwise, SNP policyholders must receive care from an in-network primary care physician or care coordinator. These two professionals will assist them with setting up treatment and services, and also provide them with referrals to specialists should they require one. The specialists will also need to be within the plan’s network.

Annual mammogram screenings, Pap tests, and pelvic exams do not require referrals.

Medicare Advantage SNP Eligibility and Enrollment

Individuals who wish to enroll in a Special Needs Plan must first enroll in Parts A and B of Original Medicare. Of course, they must also have one of the conditions that are included in the eligibility requirements for an SNP plan, and the plan must be available where they live. To be qualified for a Medicare Advantage Special Needs Plan you should either have a chronic or disabling medical condition. Other than that, developing a sudden illness that meets the qualifying criteria would also make you eligible for an SNP. Lastly, you are qualified for a Special Needs Plan if you live in a long-term care institution such as a skilled nursing facility. 

The first opportunity to enroll in a Medicare Advantage SNP is during your Initial Enrollment Period. Individuals may also enroll during the Annual Enrollment Period, which occurs each fall. If your condition is disabling, it may be possible to enroll in a C-SNP at any time of the year.

If at any point when you are enrolled in an SNP you become ineligible for the plan, you will be given a Special Enrollment Period, during which you can choose other coverage.

Medicare Advantage SNP Costs

Dual-eligible individuals will not have any costs associated with their D-SNP plan. Otherwise, the cost will vary depending on which plan you choose. Premiums for SNPs can be as low as $0 each month but may require deductibles and copayments for services. Plans are the ones that may set their own deductibles, copayments, and other cost-sharing for services.

Your Special Needs Plan may offer some extra benefits. Check with the plan directly to learn about coverage rules and restrictions for any added benefits.

Applying for an

SNP Plan

As with any other Medicare Advantage plan, an SNP must provide at least as much coverage as Medicare Parts A and B and prescription drug coverage. SNPs offer additional coverage options based on your specific medical circumstances.

Special Needs Plans are not available everywhere. You will have to check which plans are available in your area of residence to see if one is available to you. Or, you can call one of our licensed agents and they can help you search for an SNP plan or another plan that will fit your healthcare needs.

SNP Disenrollment Appeals

You may get a notice of disenrollment from your current SNP plan. If you do not agree with the terms dictating the disenrollment, you have the right to file an appeal. If the plan still disagrees, there will be an independent organization that looks over your case. These organizations are employed by the Medicare program, not the insurance company.

Before filing an appeal, you should ask your health care provider to provide any information that may help your case. In cases where your current health condition may be compromised, you can ask for a fast decision. This gives the plan 72 hours to decide on eligibility.

The plan will review its original decision to allow you into the plan. It will consider this decision during the appeal process.

If you are discharged from a hospital before you feel you are ready, you have the right to an immediate appeal and review. In this case, the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) will perform the review. While the case is being reviewed, the hospital must allow you to continue care there free of charge. The hospital may not force you to leave until the BFCC-QIO has made a decision.

Any SNP plan member who is receiving care from a skilled nursing facility, outpatient rehabilitation center, or home health agency has the right to fast-track their appeal.

When you first enroll in an SNP plan, the plan must provide details about how to file an appeal should you ever be involuntarily disenrolled from the plan.

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