Special Needs Plans

SNPs function similarly to Medicare Advantage Plans like Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Members generally receive care from providers within their plan's network, except in emergency situations. Each SNP restricts enrollment to specific groups based on defined eligibility criteria. For instance, a plan may focus on patients with chronic heart failure or diabetes, offering access to providers who specialize in managing those conditions. Drug formularies are also customized to meet the needs of individuals with those particular health conditions. SNPs often provide additional services beyond what Original Medicare covers.

These can include longer coverage periods, wellness and prevention programs, and specialized healthcare providers. Many SNPs coordinate care through designated care managers who ensure that patients receive appropriate treatments and follow recommended care plans, such as managing diet, medications, and physical activity. In cases where care coordinators are not provided, enrollees must choose a primary care physician to help manage referrals and coordinate care with specialists within the SNP’s network.

Coverage availability for SNPs varies by location, as insurers can decide where to offer plans. Additionally, insurers can provide different types of SNPs with varying costs and benefits in the same area. Individuals must continue to meet the eligibility requirements to remain enrolled in an SNP, and failure to meet those conditions could lead to disenrollment.

There are three types of Medicare SNPs, each serving a different population:

1. Dual Eligible Special Needs Plans (DSNPs) DSNPs are designed for people who are eligible for both Medicare and Medicaid. These plans help coordinate coverage between the two programs, often including additional benefits that are not available through Medicare alone. Medicare and Medicaid Eligibility To qualify for both Medicare and Medicaid, you must meet the eligibility criteria for each program. Medicare is available to individuals 65 or older or those with qualifying disabilities, while Medicaid eligibility varies by state and is based on financial need. Medicare Savings Programs (MSPs) for Dual Eligibles Certain MSPs can help cover the costs of Medicare premiums, copayments, and deductibles for individuals who are dual-eligible. These programs include:

2. Many DSNPs offer additional services like dental care, vision care, and transportation to medical appointments.

3. Institutional Special Needs Plans (ISNPs) ISNPs are tailored to individuals who live in long-term care facilities, such as nursing homes, or those who need similar levels of care. Eligibility for an ISNP requires that the individual has been living in or is expected to live in a long-term care facility for at least 90 days

4. Chronic Condition Special Needs Plans (CSNPs) CSNPs provide care for individuals with specific chronic or disabling conditions. These plans offer enhanced services for managing conditions like heart disease, diabetes, or kidney failure, which go beyond basic Medicare Part A and Part B coverage. To qualify, enrollees must have a diagnosis of a chronic condition covered by the plan. Chronic Conditions Covered by CSNPs CMS has approved the following 15 chronic conditions for CSNP eligibility:

5. Providers offering CSNPs must ensure access to specialists, medications, and services targeted to these conditions.

SNPs provide the same level of coverage as Medicare Part A and Part B and must also include prescription drug coverage (Part D). Beyond this, many SNPs offer additional benefits, such as:

SNPs may also feature lower copayments, additional wellness programs, and enhanced preventive services compared to traditional Medicare plans. However, most SNPs require enrollees to use in-network providers, though some plans allow out-of-network care at a higher cost.

Many SNP enrollees may qualify for financial assistance through Medicaid or Medicare Savings Programs to help cover the costs of premiums, copayments, and deductibles. Individuals may also qualify for a State Pharmaceutical Assistance Program (SPAP) in states where these programs are offered.

SNP eligibility is determined by the enrollee’s health condition, dual-eligible status, or institutional care needs. If you qualify, you can enroll during regular Medicare Advantage enrollment periods or use a Special Enrollment Period (SEP) based on your situation, such as entering or leaving a care facility or losing Medicaid eligibility.

If you no longer meet the eligibility criteria for an SNP (for example, if you lose Medicaid eligibility), you may be disenrolled from the plan. You will be given a grace period to find alternative coverage. During this time, you can use a Special Enrollment Period to choose a different Medicare plan without penalty.