Your Guide to Medicare Special Needs Plans

What is Special Needs Plan (SNP)?

Special Needs Plans (SNPs) are a form of Medicare Advantage plan that prevents Medicare applicants who meet certain eligibility requirements from enrolling. The advantages of these programs are designed to meet the needs of persons with medical conditions or characteristics.

Three types of Special Needs Programs (SNPs) have been designated by the Centers for Medicare & Medicaid Services (CMS):

Institutional Special Needs Plans (I-SNP): These plans are designed to support people living in an institution (such as a nursing home) or needing home nursing care.

Dual Eligible Special Needs Plans (D-SNP): These plans serve persons (also known as "dual eligible") who have both Medicare and Medicaid coverage.

Chronic-Condition Special Needs Programs (C-SNP): These plans serve recipients with some chronic conditions, such as cancer, chronic heart disease, or HIV/AIDS, that are severe or debilitating. A single chronic condition or more than one condition can be targeted by C-SNPs.

You may have specific healthcare needs that a Special Needs Plan may be best suited to meet if you fall into any of these categories. For instance, certain Special Needs Plans have a wider network of providers that specialize in treating your illness or provide formularies designed to cover the commonly prescribed prescription medications for your particular disease.

Am I eligible for special needs plan?

You must meet the following eligibility requirements to participate in a Medicare Special Needs Plan:

Confirm that you are okay with a prescription for Medicare Advantage (Part C), which includes programs for inpatients (Medicare Part A) and outpatients (Medicare Part B).

Live in the Special Needs Plan's coverage area.

Meet the eligibility criteria (i.e. reside in an institution; have Medicare and Medicaid, or have the chronic conditions(s) that the product includes) that the Special Needs Plan targets.

Usually, Medicare beneficiaries with end-stage renal disease (ESRD) are not permitted, with certain exceptions, to enroll in a Medicare Advantage Plan. However, you might be able to participate in this form of the plan if there is a Special Needs Plan targeting ESRD beneficiaries in your service area.

How do I think about medical advantage costs for special needs plans?

You will usually have the following costs, depending on the Special Needs Package (SNP):

• Expenses in cost-sharing, such as copayments, coinsurance, or deductibles*
• Medicare Part B Premium
• The additional monthly fee for extra benefits (if your SNP requires it)
• For your Special Needs Account monthly fee
• The extra monthly fee for coverage for prescription drugs (if your SNP requires it)

*Note: If you are dual-eligible (e.g., Medicare and Medicaid eligible), your Special Needs Coverage does not have higher cost-sharing requirements than you would usually pay in Part A and Part B of Medicaid or Original Medicare.

Bear in mind that, depending on whether you qualify for state financial assistance or get both Medicare and Medicaid benefits, the individual costs can differ. Your out-of-pocket expenditures will also depend on the kind of healthcare services you use and how much they are needed. Each Special Needs Plan (SNP) is different, so for the plan, you are considering to see exactly how much you will have to pay, you can check the particular Medicare Advantage SNP materials. When you use the in-network doctors of the plan and out-of-network doctors, make sure you pay special attention to the variations in the cost-sharing (if the plan allows you to go outside the network).

What does a Medical Advantage Special Needs Package cover?

Special Needs Plan for Medicare Advantage provides coverage in a single package for hospital services (Medicare Part A), medical health care needs (Medicare Part B), and prescription medications (Medicare Part D).

Special Needs Plan is available by private insurance providers that are approved by Medicare, much like all Medicare Advantage plans. All Medicare Advantage plans must have at least the same amount of coverage as Original Medicare, which includes Part A and Part B. Some Medicare Advantage plans can also provide benefits beyond what is provided by Original Medicare, and depending on where you live, the Medicare plan choices and benefits can differ.

To help you better understand your condition and adhere to your medication schedule, certain Special Needs Plans provide care-coordination services. Or to assist with a particular diet or other lifestyle habits that can help enhance your condition, you may have access to wellness services.

Chronic-Condition Special Needs Plans (C-SNPs) may provide provider networks of doctors and hospitals specialized in the care of their participants' particular condition or may include formularies customized to provide prescription medications to treat the disease.

If you are enrolled in a Dual Qualified Special Needs Plan (D-SNP), some social services might be available to better manage your Medicare and Medicaid benefits.

It is important to remember that you will have all the coverage that is otherwise provided with Original Medicare, Part A and Part B, and Medicare Part D with an SNP. The Special Needs Plan simply includes additional coverage to help you better handle your specific condition, whether it is living in a nursing home, coordinating your benefits from Medicare and Medicaid, or treating a significant chronic disease.

What conditions are included as part of the Special Needs Plan for Chronic Conditions?

For those with these conditions, the Center for Medicare and Medicaid Services requires C-SNPs to be provided.

• AIDS/HIV
• Chronic lung disorders
• Mental health problems that are chronic and debilitating
• Neurologic disorders
• Chronic alcohol and other addictions
• Inflammatory diseases
• Cancer (excluding pre-cancer conditions)
• Diabetes Mellitus
• End-stage cancer of the liver
• Dialysis-requiring end-stage renal disease (ESRD)
• Serious diseases of hematology- Stroke
• Cardiovascular irregularities
• A recurrent weakening of the heart
• Dementia

Any Medicare SNP restricts its membership to individuals in one of these categories, or a subset of one of these groups, according to the Centers for Medicare and Medicaid Services. A Medicare SNP, for example, could be intended to only support people diagnosed with congestive heart failure. Access to a network of providers that specialize in treating congestive heart failure will be included in the package.

Clinical case management systems tailored to support the special needs of individuals with this disorder will also be included. The medication type of the package will be intended to cover the medications currently used for the treatment of congestive heart failure. People who enter this plan would receive benefits explicitly tailored to their illness, and through Medicare, SNP would have all their treatment arranged.

The key distinction between a Special Needs Plan (SNP) and all forms of Medicare Advantage Plans is that prescription drugs must be provided by all SNPs. In addition, depending on the particular plan, some Medicare Advantage plans (for example, HMOs and PPOs) may or may not provide prescription drug coverage.

Getting Help With Special Needs Plan Cost

If you have both Medicare and Medicaid, or if you have reduced income, Medicaid will be eligible to pay some or all of the premiums and/or out-of-pocket costs of your Medicare Advantage Special Needs Plan. You can qualify for a Medicare Savings Program based on your salary, which may help pay for expenses like premiums, copayments, coinsurance, or deductibles.

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