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What are Special Needs Plans?

Medicare Advantage Special Needs Plans (SNPs) are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, SNPs must provide you with the same benefits, rights, and protections as Original Medicare, but they add the additional support for special conditions. Some SNPs offer additional benefits, such as vision and hearing care.

There are three types of Special Needs Plans (SNPs) available:

  1. Chronic-Condition Special Needs Plans (C-SNP): These plans serve beneficiaries with certain severe or disabling chronic conditions, such as diabetes, heart conditions, stroke, COPD, and others. Chronic-Condition Special Needs Plans may target a single chronic condition or multiple conditions.

  2. Institutional Special Needs Plans (I-SNP): These plans serve those living in an institution (such as a nursing home) or who need nursing care at home.

  3. Dual-Eligible Special Needs Plans (D-SNP): These plans serve people who have both Medicare and Medicaid benefits (also known as “dual eligibles”). Partial Medicaid recipients – with a share of cost – may not be eligible for Dual-Eligible Special Needs Plans.

If you fall into any of these categories, you may have unique healthcare needs that a Special Needs Plan may be better equipped to address. For example, some Special Needs Plans offer a larger network of providers that specialize in treating your condition or have formularies that are tailored to cover the prescription drugs typically prescribed for your particular illness. Some may even offer these benefits at lower or possibly no copays.

Eligibility for Special Needs Plans

To enroll in a Medicare Special Needs Plan, you must meet the following eligibility requirements:

  1. Be enrolled in Medicare Part A and Part B.

  2. Live in the service area of the Special Needs Plan.

  3. Meet the eligibility requirements that the particular Special Needs Plan (i.e. live in an institution; have Medicare and Medicaid; or have the chronic conditions(s) for that plan).

Medicare beneficiaries with end-stage renal disease are typically not allowed to enroll in a Medicare Advantage plan; however, if there is a Special Needs Plan tailored for those diagnosed with end-stage renal disease in your service area, you may be eligible to enroll in this type of plan.

IMPORTANT NOTE! You can enroll in a Special Needs Plan once you’re first eligible for Medicare if there is a Special Needs Plan in your service area for your specific need and you meet the eligibility requirements of that plan. So, if you meet any of the conditions above to enroll into a Special Needs Plan, then you can enroll into the plan starting the first of the next month.

Keep in mind that you can only remain enrolled in a Special Needs Plan for as long as you meet the qualifying conditions of that plan. If your situation changes and you no longer meet the enrollment requirements for the Special Needs Plan, you’ll get a Special Election Period to switch to a different Medicare Advantage plan or return to Original Medicare.

For example, if you’re in a Chronic-Condition Special Needs Plan (C-SNP) and no longer have the condition that the Special Needs Plan is tailored for, you’ll be disenrolled from the plan and given a Special Election Period to make a different enrollment choice. Similarly, if you lose your Medi-Cal (Medicaid) eligibility and are enrolled in a Dual-Eligible Special Needs Plan (D-SNP), you may qualify for a Special Election Period to make coverage changes.

Medicare Advantage Special Needs Plans Benefits

Medicare Advantage Special Needs Plans include coverage for hospital services (Medicare Part A), medical healthcare needs (Medicare Part B), and prescription drugs (Medicare Part D) through a single all-inclusive plan. One key difference between a Special Needs Plan and other types of Medicare Advantage plans is that all Special Needs Plans MUST cover prescription drugs.

Some Special Needs Plans include care-coordination services to help you better understand your condition and stick to your doctor’s treatment regimen. Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition. If you’re enrolled in a Special Needs Plan for dual-eligibles, there may be certain social services available to help you coordinate your Medicare and Medicaid benefits. You will have you Medicare, Medi-Cal (Medicaid), and drug benefits coordinated through one card instead of three.

It’s important to note that the standard coverage requirements remain for Original Medicare Part A and Part B, and Medicare Part D. The Special Needs Plan simply offers extra coverage to help you better manage your particular situation; whether that’s living in a nursing home, coordinating your Medicare and Medicaid benefits, or treating a serious chronic illness.

What is a care coordinator in a Medicare SNP?

Some Medicare Advantage Special Needs Plans (SNP) use a care coordinator to help you stay healthy and follow your doctor’s orders. A care coordinator is someone who helps make sure beneficiaries receive the right care and information.

For example, a Medicare SNP for those with diabetes might use a care coordinator to help members accomplish the following:

  1. Monitor their blood sugar

  2. Follow their diet

  3. Get proper exercise

  4. Schedule preventive services (like eye and foot exams)

  5. Access the right prescriptions to prevent complications

A Medicare SNP for those with both Medicare and Medicaid might use a care coordinator to help members accomplish the following:

  1. Access community resources

  2. Coordinate their different Medicare and Medicaid services

A care coordinator can often be an invaluable resource for members. They can be useful for information as well as personal support. More importantly they can help be an advocate to ensure you are receiving the care that you need.

Special Needs Plans are not available everywhere in the United States. To look up whether Special Needs Plans are available in your service area, we recommend partnering with a broker to help research the options available to you based on the criteria we have explained above.