What is a Medicare Special Needs Plan?

Medicare Special Needs Plans (SNPs), like all Medicare Advantage Plans, are provided through private insurance companies that Medicare approves. And just like Medicare Advantage Plans, SNPs must provide you with the same benefits, rights, and protections as Original Medicare, with one exception; they must include coverage for prescription drugs. SNPs are designed to provide additional services for patients who need specialized inpatient and outpatient care. To qualify, a patient must fall into at least one of the following three categories:

  • Chronic Condition SNPs (C-SNPs): For patients with specific chronic conditions, such as cancer, dementia, diabetes, HIV/AIDS, stroke, End-Stage Renal Disease (ESRD), and certain neurological disorders
  • Institutional SNPs (I-SNPs): For patients who live in an institution; such as a nursing home, long-term care skilled nursing facility, intermediate care facility, or assisted living facility
  • Dual Eligible SNPs (D-SNPs): For patients enrolled in both Medicare and Medicaid

Unfortunately, SNPs are not available everywhere. To determine if an SNP is available in your area, you can call 1-800-MEDICARE or visit your State Health Insurance Assistance Program (SHIP) at www.shiptacenter.org. AARP and other national senior advocacy programs also offer services to help you find the available coverage. 

What Kind of Benefits Does a Medicare SNP Provide?

All Medicare Special Needs Plans (SNPs), including Medicare Parts A, B, and D. Some SNPs include additional services to help you better understand your condition, symptoms and the treatments prescribed by a physician. You may even have access to wellness, exercise, and nutritional programs that help treat conditions like diabetes. Chronic-Condition Special Needs Plans may include provider networks, physicians, and facilities that focus solely on treating illnesses like cancer, dementia, or End-Stage Renal Disease.

Suppose you have qualified for both Medicare and Medicaid and are on a limited income. In that case, Medicaid may cover some or all of your Medicare Advantage SNP premiums and healthcare-related costs. Depending on your income levels, you may also qualify for a Medicare Savings Program that helps pay for unexpected expenses such as higher premiums, copayments, coinsurance, or deductibles. With some plans, you may receive a Flex Card that can be used as a debit card for buying approved out-of-pocket health-related expenses that your provider supports. Those could be deductibles, co-pays for office visits or prescriptions, insulin, or medical devices such as blood pressure cuffs. SKU or UPCs verify purchased items. 

How much Does a Special Needs Plan Cost?

In most cases, you will still need to pay your Medicare Part B premium. Added to that will be the SNP monthly premium that your plan provider determines. There are a variety of plans, with a wide range of costs available, so take your time and select your plan carefully. And even though SNPs are required to provide prescription drug coverage, there may be an additional monthly premium for them.

Keep in mind that your Medicare SNP may be provided by a Health Management Organization (HMO) or a Preferred Provider Organization (PPO). Depending on the plan you’ve selected, you may need to see in-network providers receive coverage. You may also have the option of paying extra for visiting practitioners that are considered out-of-network.

What is a Dual Special Needs Plan (DSNP)?

Some people are eligible to carry both Medicare and Medicaid and qualify to enroll in a special kind of Medicare Advantage plan known as a Dual Special Needs Plan (D-SNP). A Dual Special Needs Plan is a special kind of Medicare Advantage plan that combines Medicare Part A, Part B, and Part D prescription drug coverage. Patients have access to both Medicare and Medicaid benefits that may include vision, dental or fitness plans.

If you’re enrolled in an SNP as a “dual eligible” individual, you may have access to certain additional social services that can help you coordinate your Medicare and Medicaid benefits. It is helpful to have an advocate who can teach you how to navigate the challenges of working with two very different systems. You may also qualify for transportation services to and from appointments, telehealth visits, and worldwide emergency coverage. 

To be eligible for DSNP, you must meet the following criteria:

  • Already enrolled in Medicare and Medicaid
  • Low-income seniors age 65 and older
  • Patients with disabilities who are younger than age 65 
  • You already have Medicare Part A and Part B 
  • You live in an area where a DSNP plan is offered


Medicare Advantage Special Needs Plan Enrollment

Most seniors are first eligible for Medicare during their Initial Enrollment Period, the seven-month period that starts three months before your 65th birthday, includes your birthday month, and ends three months later. Suppose you qualify for Medicare because of disability. In that case, your Initial Enrollment Period starts three months before the 25th month that you are receiving Social Security or Railroad Retirement Board disability benefits and lasts seven months.

You can also enroll in a Special Needs Plan during the Annual Election Period from October 15 to December 7 each year. During this open enrollment period, you can enroll in a Special Needs Plan or a Dual Special Needs Plan for the first time, switch plans or providers, or disenroll from your current plan.

You may also be qualified to enroll in a Special Election Period outside of these periods under certain circumstances. For example, if you are diagnosed with one of the qualifying chronic conditions such as a stroke, cancer, HIV/AIDS, or diabetes.

Conversely, if you’re in a Chronic-Condition Special Needs Plan and no longer have the condition that the Special Needs Plan covers, you’ll be disenrolled from the SNP. Then you’ll be given a Special Election Period to enroll in a different Medicare Advantage plan or return to Original Medicare. Similarly, suppose you are enrolled in a Dual Special Needs Plan, and you lose your Medicaid eligibility. In that case, you may qualify for a Special Election Period to make changes to your coverage.

Your life can change in an instant, so it’s good to know that there are a variety of plans like SNPs and DSNPs to help you pay for unexpected medical expenses. Choosing the right coverage can be a daunting task, especially when you’re ill. Do your research, take your time, and don’t be afraid to ask for help.