Diagnosis of a Qualifying Chronic Illness

Medicare recipients who have been diagnosed with a qualifying chronic illness have a very special opportunity afforded to them to add, drop or change their Medicare Advantage and/or Prescription Drug plan(s) through the Special Election Period (SEP). The SEP is an eligibility period available specifically to Medicare recipients who have been diagnosed with certain qualifying illnesses. It enables Medicare plan changes outside of the Annual Enrollment Period (AEP).

What can I do?

Join a Medicare Chronic Special Needs Plan (CSNP). The plan must be available within your zip code and it must be regarding your specific chronic illness. Below are some common qualifying chronic illnesses

When can I do this?

You can join anytime, but once you join, your chance to make changes using this SEP ends. However, if the diagnosis of a new chronic illness is made by a licensed healthcare practitioner and you have already used the one-time per year SEP, due to the additional (new) chronic illness diagnosis a new SEP is available. For example, Medicare client enrolled into CSNP plan for diabetes in June. In July the Medicare client is diagnosed with a severe heart condition and therefore is now eligible (again) for SEP. Therefore if the Medicare client desires to change plans to go onto a CSNP plan that is for heart disease instead of Diabetes, this change can be accomplished.

15 Specific Chronic Conditions

1. Chronic alcohol and other drug dependence

2. Autoimmune disorders limited to...

  1. Polyarteritis nodosa
  2. Polymyalgia rheumatica
  3. Polymyositis
  4. Rheumatoid arthritis
  5. Systemic lupus erythematosus

3. Cancer, excluding pre-cancer conditions or in-situ status

4. Cardiovascular disorders limited to...

  1. Cardiac arrhythmias
  2. Coronary artery disease
  3. Peripheral vascular disease
  4. Chronic venous thromboembolic disorder

5. Chronic heart failure

6. Dementia

7. Diabetes Mellitus

8. End-stage liver disease

9. End-Stage Renal Disease (ESRD) requiring dialysis

10. Severe hematologic disorders limited to...

  1. Aplastic anemia
  2. Hemophilia
  3. Immune thrombocytopenic purpura
  4. Myelodysplastic syndrome
  5. Sickle-cell disease (excluding sickle-cell trait)

11. HIV/AIDS

12. Chronic lung disorders limited to...

  1. Asthma
  2. Chonis bronchitis
  3. Emphysema
  4. Pulmonary fibrosis
  5. Pulmonary hypertension

13. Chronic and disabling mental health conditions limited to...

  1. Bipolar disorders
  2. Major depressive disorders
  3. Paranoid disorder
  4. Schizophrenia
  5. Schizoaffective disorder

14. Neurologic disorders limited to...

  1. Amyotrophic lateral sclerosis (ALS)
  2. Epilepsy
  3. Extensive paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia)
  4. Huntington’s disease
  5. Multiple sclerosis
  6. Parkinson’s disease
  7. Polyneuropathy
  8. Spinal stenosis
  9. Stroke-related neurologic deficit

15. Stroke

The list of SNP-specific chronic conditions is not intended for purposes other than clarifying eligibility for the C-SNP CCP benefit package. CMS may periodically re-evaluate the fifteen chronic conditions as it gathers evidence on the effectiveness of care coordination through the SNP product, and as health care research demonstrates advancements in chronic condition management.