Medicare Special Needs Plan: Cost, Eligibility, & More

• Special Needs Plans (SNPs) are Medicare Advantage (MA) plans for those that qualify for Medicaid benefits or live with certain diseases or chronic conditions. 

• There are four specific types of SNPs known as Dual Special Needs Plans (D‑SNPs), Chronic Special Needs Plans (C‑SNPs), Institutional Special Needs Plans (I‑SNPs), and Institutional-Equivalent Special Needs Plans (IE-SNPs).

• Eligibility for a Medicare Special Needs Plan is based on the plan type and the qualifications it requires a beneficiary to have.

• Exactly what benefits each Special Needs Plan offers will differ to accommodate the unique health care costs and needs of the communities they cater to.

Original Medicare typically includes Part A (hospital insurance) and Part B (medical insurance) coverage. Original Medicare does not include prescription drug coverage. Beneficiaries would have to join a separate Medicare drug plan known as Medicare Part D.

Many beneficiaries can opt to join privately insured supplement plans known as Medicare Advantage (MA) plans. MA plans bundle standard Medicare coverage with additional benefits such as Part D prescription drug coverage alongside dental, hearing, and vision coverage.

There are many types of Medicare Advantage plans, including Medicare Advantage Special Needs Plans (SNPs).

A Special Needs Plan, commonly called an SNP, is a type of Medicare Advantage plan. Medicare SNPs limit membership to those that either have Medicaid eligibility or live with certain diseases or chronic conditions. 

Like all Medicare Advantage plans, SNPs are provided by private insurance companies that are Medicare-approved. SNPs uniquely tailor their plan’s benefits, providers, and prescription drug coverage to the communities that they cover. However, generally speaking, all MA plans (including SNPs) bundle Part A and Part B coverage in addition to extra benefits such as hearing, vision, and prescription drug coverage.

Most SNPs require a primary care provider and limit beneficiaries to seek out in-network care, however, select plans offer out-of-network coverage as well. Coverage options for providers and prescription drugs depend on the specific Special Needs Plan chosen. Prior to selecting an MA plan or seeking care, one should check with their health insurance company to ensure their desired services are covered.

When it comes to selecting an SNP, one has four options to choose from: Dual Special Needs Plans (D‑SNPs), Chronic Special Needs Plans (C‑SNPs), Institutional Special Needs Plans (I‑SNPs), and Institutional-Equivalent Special Needs Plans (IE-SNPs).

Dual Special Needs Plans (D‑SNPs)

D‑SNPs are commonly called ​“Dual Eligibles” plans as they combine Medicare and Medicaid coverage for beneficiaries that qualify for both programs. With Dual Eligible Special Needs Plans, Medicare acts as the primary health insurance and Medicaid acts as the supplemental insurance.

Note: To learn more about D‑SNPs, visit this federal government website.

Chronic Special Needs Plans (C‑SNPs)

C‑SNPs are for individuals that are living with severe or disabling chronic conditions. Presently, there are fifteen chronic conditions that make a beneficiary eligible for a C‑SNP including:

• Alcohol or Drug Dependencies

• Autoimmune Disorders, e.g., polyarteritis nodosa, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, etc.

• Cancer

• Cardiovascular Disorders, e.g., cardiac arrhythmias, coronary artery disease, peripheral vascular disease, etc.

• Chronic Heart Failure

• Dementia

• Diabetes Mellitus

• End-Stage Liver Disease

• End-Stage Renal Disease (ESRD)

• Hematologic Disorders, e.g., aplastic anemia, hemophilia, sickle-cell disease, etc.

• HIV/​AIDs

• Lung Disorders, e.g., asthma, chronic bronchitis, emphysema, etc.

• Mental Health Disorders, e.g., bipolar disorders, depressive disorders, paranoid disorder, schizophrenia, etc.

• Neurological Disorders, e.g., amyotrophic lateral sclerosis (ALS), epilepsy, Huntington’s disease, etc.

• Stroke

C‑SNPs vary in benefits and coverage depending on the specific plan selected. Not to mention, certain health insurance companies may differ on what C‑SNPs they offer. It’s important for beneficiaries to discuss their plan options with a licensed insurance agent prior to selecting a plan.

Note: To learn more about C‑SNPs, visit this source.

Institutional Special Needs Plans (I‑SNPs)

I‑SNPs are available for beneficiaries that reside in skilled nursing facilities such as nursing homes. In order to qualify for an I‑SNP, a beneficiary must be expected to need the level of services provided through:

• Long-term care at a skilled nursing facility

• Long-term care at a nursing facility

• Intermediate care at a facility for those with intellectual disabilities

• Care at a psychiatric facility

Note: To learn more about I‑SNPs, visit this source.

Institutional-Equivalent Special Needs Plans (IE-SNPs)

IE-SNPs are similar to I‑SNPs, however, they are meant for beneficiaries living in a contracted assisted living facility. Those that qualify for IE-SNPs also require the type of care and assistance that is provided at a skilled nursing facility.

Different SNPs require different eligibility requirements. 

• D‑SNP Eligibility: In order to qualify for D‑SNPs, a beneficiary must be eligible for both Medicare and Medicaid services. 

• C‑SNP Eligibility: In order to qualify for C‑SNPs, a beneficiary must live with one of the chronic conditions listed above.

• I‑SNP Eligibility: In order to qualify for I‑SNPs, a beneficiary must reside in a skills nursing facility and require a certain level of care assistance.

Depending on the Special Needs Plan chosen, health care services covered and benefits may vary. However, most Medicare Advantage SNPs provide Original Medicare coverage (Part A and Part B) in addition to Part D, hearing, dental, and vision coverage. Certain plans also cover health costs associated with a personal emergency response system as beneficiaries with SNPs are more likely to request emergency medical help.

Prior to selecting a plan, one should speak with a licensed insurance provider about the coverage and benefits options provided within a specific plan.

However, since a Medicare Advantage SNP requires a beneficiary to select a primary care physician (PCP), they can expect to have coordinated health care by their chosen primary care doctor.

Depending on the Special Needs Plan chosen, costs for annual deductibles, monthly premiums, coinsurance coverage, and copayments may vary. For more information on costs related to a specific Special Needs Plan, beneficiaries should speak with a licensed insurance agent.

However, regardless of the specific plan chosen, all MA plan beneficiaries are required to pay their Part B premium which is projected to be approximately $158.50 per month in 2022.

Any eligible Medicare beneficiary is able to enroll in an SNP during their Medicare annual enrollment period otherwise known as the initial enrollment period (IEP), switch their plan during the open enrollment period (OEP), or enroll in an MA plan during the general enrollment period (GEP). The dates for these enrollment periods are as follows:

Initial Enrollment Period

The IEP spans a total of seven months and is the same as Original Medicare’s IEP. These seven months include three months prior to an individual’s 65^th birthday, the month of one’s 65^th birthday, and the three months following one’s 65^th birthday. 

Open Enrollment Period

October 15^th to December 7^th is considered Medicare’s OEP and it allows beneficiaries to switch their current plan, e.g., switch from Original Medicare to an MA plan, switch from one MA plan to another, etc.

General Enrollment Period

The GEP for Medicare Advantage spans from April 1^st to June 31^st and is an additional timeframe for eligible individuals to register for a MA plan.

Note: To learn more about Medicare Advantage’s enrollment periods for SNPs and more, visit this source.

Which consumer may be a good candidate for a D-SNP?

Someone who would want to consider a D-SNP is a person who is eligible for both Medicare and Medicaid. People over the age of 65 who are not on Medicaid, but who receive Extra Help or state assistance, could also be a good fit for a D-SNP.

What are some distinct advantages of a SNP plan?

The biggest advantages of a SNP plan are the additional benefits provided such as hearing, dental, and vision care. SNP plans may also provide other benefits that can be helpful for certain conditions.