Medicare Special Needs Plan

Medicare was created to serve the needs of seniors and disabled persons who meet the requirements. As a form of universal health care, it's a low-cost, robust program that provides access to benefits ranging from wellness services to hospice care. In order to better serve clients, Medicare has created a range of Medicare Advantage Plans, including Special Needs Plans (SNP) that are designed to fill specific medical needs for seniors who are in assisted living environments or living with chronic conditions.

What Is A Medicare Special Needs Plan?

Medicare Special Needs Plans are Medicare insurance plans that are available through Medicare Advantage (Medicare Part C). They're similar to HMOs and PPOs, but enrollment is limited to seniors who have specific diseases or chronic medical conditions.

If you qualify to join an SNP program, your choice of providers, the range of benefits, and prescription drug availability are tailored to those that have been determined to best meet the requirements of your group or condition. The plan providers usually include specialists in conditions or diseases that afflict their members.

Who Is Eligible?

Medicare Special Needs Plans are restricted to Medicare-eligible recipients who live in a nursing home, who need in-home skilled nursing care, or who have chronic or disabling conditions like chronic heart failure, HIV/AIDS, End-Stage Renal Disease (ESRD), and dementia or Alzheimer's. Some plans may have further restrictions, and you can join at any time after you've been diagnosed with a qualifying condition.

The SNP program has three different plans, including Dual-Eligible Special Needs Plan for those who meet multiple eligibility requirements.

Medicare Advantage Special Needs Plans Requirements

The requirements to qualify for membership in any of the Medicare Special Needs Plans are pretty straightforward. You must:

You must be enrolled in Medicare Part A and Part B.
You must live within the plan's service area.
You must have a living situation or medical condition that meets the eligibility for one of the SPNs.

There are three Medicare Special Needs Plans: Chronic-Condition Special Needs Plan (C-SNP), Institutional Special Needs Plan (I-SNP), Dual-Eligible Special Needs Plan (D-SNP). In order to qualify for an SNP, you must fall within the guidelines for membership or at least one subset of one of the plans. You'll no longer qualify if your circumstances change.

What Do Special Needs Plans Cover?

Any medical service that's covered under Original Medicare is required under a Medicare Special Needs Plans. You may receive additional services according to your type of plan and covered condition or living situation. For example, a Chronic-Condition Special Needs Plan would also cover medications, therapies, medications, and treatments that are deemed necessary to manage your condition but might not be available under a standard Medicare plan.

Do Special Needs Plans Cover Prescription Drugs?

All Medicare Special Needs Plans are required to cover prescription medications. This includes common prescription medications and special formulations required to treat the patient's specific disability or chronic medical conditions.

The 3 Types Of Medicare Special Needs Plans

These Medicare plans are designed to provide additional health care benefits above routine hospitalization and medical care for seniors or disabled individuals with special circumstances.

Special Needs Plans are restricted to members who have extremely low incomes and are over 65 (Dual-Eligible Special Needs Plan), who are diagnosed with a chronic medical condition or debilitating disease (Chronic-Condition Special Needs Plan), who need full- or part-time, in-home Skilled Nursing Care, or patients who are confined to a nursing home or convalescent center (Institutional Special Needs Plan).

Chronic-Condition Special Needs Plan (C-SNP)

The Chronic-Condition Special Needs Plan is the most comprehensive of all of the Medicare Advantage Special Needs Plans. It covers additional medications, therapies, and treatments for specific serious medical conditions. You're covered for care related to the following medical conditions if they are deemed chronic and disabling:

Chronic alcohol and other dependencies
Autoimmune disorders
Cancer (other than pre-cancerous conditions)
Cardiovascular disorders
Chronic heart failure
Dementia
Diabetes mellitus
End-stage liver disease
End-Stage Renal Disease (ESRD) requiring any mode of dialysis
Severe hematologic disorders
HIV/AIDS
Chronic lung disorders
Chronic and disabling mental health conditions
Neurological disorders
Stroke

Institutional Special Needs Plan (I-SNP)

Seniors are eligible for the Institutional Special Needs Plan subset of Medicare Special Needs Plans if they are moved to a nursing home, an assisted living facility, or if they need at-home care. You'll remain enrolled in this plan for as long as you need to live in a medically supervised environment. The only exception is hospice care, which is covered by your Medicare Part A policy.

Dual-Eligible Special Needs Plan (D-SNP)

You qualify to enroll in a Dual-Eligible Special Needs Plan if you're disabled and/or over the age of 65, and you meet all other eligibility requirements for Medicare and Medicaid. You'll be able to remain with this SNP for all long as you meet those conditions.

How Special Needs Plans Work?

Medicare Special Needs Plans work in much the same way as an HMO. Your plan will offer a list of in-network facilities, primary care physicians, and specialists. If any provision in your service area drops out of the plan, you'll be notified and offered an alternative.

All of your medical care and services must be provided by the network-approved doctor or medical facility in order for the cost of the care to be covered by your plan. The only exceptions are:

Emergency room visits or urgent care for sudden illnesses or treatment that can't wait, such as a broken bone or heart attack.
Treatment for End-Stage Renal Disease (ESRD) if the dialysis facility is in another area.

Do You Need a Primary Care Physician?

Medicare Advantage Special Needs Plans to have two options. You can either have a primary care physician (PCP) or a care coordinator who manages your health care. Medicare prefers it if members have a PCP, but they must be in the network and service area.

Do You Need a Referral To See A Specialist?

Most patients with Medicare Advantage Special Needs Plans will need a referral if they have to see a specialist. Some exceptions are for in-network routine PAP tests and pelvic exams every two years and annual mammogram screenings. Check with your plan's provider for other exceptions to your specific plans.