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Medicare Advantage Special Needs Plans

Summary: Medicare Special Needs Plans are an alternative to Original Medicare aiming to better take care of the healthcare needs of those with certain chronic conditions or diseases. There are three different types of SNP Medicare coverage options available. It’s also important to understand the limitations and guidelines of your plan as they vary from SNP to SNP. Be sure to compare Medicare Advantage Special Needs Plans before enrolling to find the right coverage for your needs. Estimated Read Time: 5 mins

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Table of Contents:

  1. What Are Medicare Special Needs Plans?
  2. The Three Types of Special Needs Plans Are
  3. Chronic-Condition Medicare Special Needs Plan
  4. Institutional Medicare Special Needs Plan
  5. Dual-Eligible Medicare Special Needs Plan
  6. What Are the SNP Medicare Plan Limitations?
  7. How Much Do SNP Medicare Advantage Plans Cost?
  8. Who Qualifies for Medicare Special Needs Plans?
  9. How to Appeal a Special Needs Plan Disenrollment Notice?
  10. How to Get Help Applying for Medicare Advantage Special Needs Plans

Medicare Special Needs Plans offer tailored plan options to Medicare enrollees with certain health or economic issues. Just as all people have individual medical needs, not all health conditions are generic. You may find your medical needs can be complex, but this doesn’t mean your coverage should be too. SNP Medicare plans are available to help simplify your coverage with plans designed for your situation.

What Are Medicare Special Needs Plans?

Medicare Special Needs Plans give you specific coverage for chronic or disabling conditions. SNPs have three different categories for health coverage. Medicare Advantage Special Needs Plans also limit membership to one of the three plan types.

The Three Types of Special Needs Plans Are

If any of the below categories apply to you, you may have exceptional healthcare needs. Here are the three types of healthcare needs qualifying for a Medicare SNP:

  • Chronic Condition SNP (C-SNP)
  • Institutional SNP (I-SNP)
  • Dual-Eligible SNP (D-SNP)

Chronic-Condition Medicare Special Needs Plan

C-SNPs are for Medicare beneficiaries who suffer from certain severe and/or disabling, incurable conditions. Conditions include one or more of the following: cancer, dementia, diabetes, End-Stage Renal Disease (ESRD), Medicare coverage for epilepsy, chronic heart failure, and HIV/AIDS.

Institutional Medicare Special Needs Plan

I-SNPs are for certain beneficiaries living in institutions such as nursing homes. I-SNP Medicare coverage is also for those who need at-home health or nursing care for certain illnesses.

When applying for an I-SNP, you’ll need to include proof of institutionalization for at least 90 days. You could be eligible even if you’re receiving nursing care in a home instead of at a facility.

Dual-Eligible Medicare Special Needs Plan

Beneficiaries who have both Medicare and Medicaid coverage are dual-eligible. D-SNPs provide coverage to these individuals based on the level of help they receive. However, not all Dual Eligible plans are available for all types of Medicaid. You will be able to see which plan accepts your level of Medicaid in the plan’s Summary of Benefits.

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What Are the SNP Medicare Plan Limitations?

SNP plans must provide the same service options, coverage, benefits, protections, and rights that Original Medicare offers. However, Medicare SNP plans may have different rules, costs, and restrictions. Special needs plans have restrictions that may include receiving healthcare and services from providers within the SNP’s network.

With that being said, each Special Needs Plan with Medicare will also have exceptions. For example, if a beneficiary suffers a sudden illness requiring the E.R. or urgent care services or if a beneficiary has ESRD requiring dialysis out of the service area.

A Medicare Special Needs Plan requires beneficiaries to use an in-network primary care physician or care coordinator to assist with healthcare. Referrals to see specialists in the Medicare Advantage Special Needs Plan’s network are often required. On the other hand, some services or specialists don’t require referrals; specifically, annual mammogram screenings and pap tests/pelvic exams.

How Much Do SNP Medicare Advantage Plans Cost?

If you have both Medicare and Medicaid, your Medicare Advantage SNP will likely have a zero-dollar premium. However, your costs will depend on your level of Medicaid coverage.

If you do not qualify for Medicaid, then it is unlikely that you will qualify for Medicare Special Needs Plans will vary depending on your situation and the plan you choose. Premiums can be as low as zero dollars and require no deductibles or copayments.

Who Qualifies for Medicare Special Needs Plans?

If you meet the following guidelines, you can qualify for a Medicare Special Needs Plan. Here’s who can enroll in an SNP:

  • You are eligible for Original Medicare (Parts A and B).
  • You have a primary residence in an SNP’s service area.
  • You meet the requirements of your individual SNP, which can vary by carrier.

How to Appeal a Special Needs Plan Disenrollment Notice?

If you happen to get a notice of dis-enrollment, and you don’t agree with the terms – you have the right to file an appeal. Should your plan disagree with your appeal, an independent organization will look over the forms. These organizations work for Medicare, not for your SNP plan. So, no need to worry about a biased decision.

However, what you do before filing your Medicare SNP appeal will make a huge difference. Here’s how to handle things before filing an appeal for a smoother process:

  • Ask your healthcare provider and/or supplier for any information that might help prove your case.
  • If health status is a concern, request a fast decision. Once your SNP Medicare carrier or doctor agrees, the plan then has 72 hours to decide.
  • When you enroll in a Medicare Special Needs Plan, the plan must state (in writing) how to make an appeal. Once you’ve filed an appeal accordingly, your SNP will look over its original decision for dis-enrollment.
  • If discharged from a hospital before ready, you have the right to an immediate review. The Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) does this review. While your case is under review, the hospital must allow you to stay free of charge. Prior to the BFCC-QIO’s decision, the hospital CAN NOT force you to leave.
  • Anyone receiving care in a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation center has the right to a fast-track appeal.

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How to Get Help Applying for Medicare Advantage Special Needs Plans

SNP Medicare coverage offers healthcare insurance to help the management of your specific circumstance or disease. Working with a licensed insurance agent can help you compare your options and find the right plan for you.

Medicare Special Needs Plans are not offered everywhere. Check your service area for plan options or talk to one of our agents today by calling the number above. If you’re not able to call now, fill out our online rate form.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Special Needs Plans, Medicare. Accessed December 2023.
    https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/special-needs-plans-snp
  2. How Medicare Special Needs Plans Work, Medicare. Accessed December 2023.
    https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/how-medicare-special-needs-plans-snps-work
  3. Special Needs Plans, CMS. Accessed December 2023.
    https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans
  4. Request for Information on Severe and Disabling Chronic Conditions and Enrollment in Medicare Advantage Chronic Condition Special Needs Plans (C-SNPs), CMS. Accessed December 2023.
    https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/Downloads/RFI-Chronic-Condition-SNP-Panel.pdf
  5. Institutional Special Needs Plans (I-SNPs), CMS. Accessed December 2023.
    https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans/institutional
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare educator serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

11 thoughts on "Medicare Advantage Special Needs Plans"

  1. Hello! My mother has both Medicare & Medicaid in Ohio. Eventually her condition will be such that I will need to relocate her to Georgia. Is it possible that her eligibility will transfer, thou the Medicaid benefits could be different between the states? Have no idea how to approach this but got to start somewhere. Thank you!

    1. Medicaid benefits vary from state to state, however, Original Medicare benefits stay the same nationwide. If she has dual coverage in Ohio, she should qualify in Georgia as well, however income limits could vary. It would be best to start with calling the Georgia Medicaid office to receive information on income limits and if your mother would qualify.

  2. I am a 54 year old non-smoking disabled woman in upstate NY. Starting May 2022, I will receive SSDI at 1,989 per month and part B will be deducted automatically. I worked for 30 years, which, I believe, means there will be no deduction for part A. I live alone and 1,989 barely covers my rent and other needs, let alone taking 170 dollars out for part B. Do I qualify for any type of financial help? I spoke to Medicare and was told that Original Medicare is much better to use than a private insurance. I don’t think I can afford it and should probably let a private insurance handle everything including vision and dental. Do any of them help pay for the part B premium? I’m worried because I had a stroke and now live with sleep apnea, high blood pressure, diabetes and Graves disease, with monthly thyroid bloodwork checks, eye checks for thyroid and diabetes, CPAP equipment, and a lot of dental work in my future. It looks like I am not poor enough for Medicaid or Special Needs or Extra Help or any financial help. Do I have any options?

    1. Susan, it looks like your income would be over the limits for these programs. You should consider the deductible, copays, and coinsurances of an advantage plan before committing to advantage over a supplement. I recommend speaking to a licensed agent who can help you fully understand your available options.

    2. Susan, I have Humana Gold Choice SNP, special needs program because my income is low. From what I have been reading your diabetes and the cost of living in New York probably makes you eligible for their program if it’s in New York. I have been on disability for almost 20 years Other than 2 horrible years with another company, I have always had Humana plans.

  3. If individual had a liver transplant 6 years ago and has to take daily anti rejection meds and have special appointments for follow up, would they be eligible for a snp?

    1. Hi Fran – the individual would be eligible for an SNP if they’re dual-eligible for Medicare and Medicaid or if the liver condition is considered chronic or disabling. Additionally, if they live in a facility such as a nursing home or receive home health care, they would be eligible.

  4. Jagger, can you clarify for me the difference between an I-SNP and a MAPD? I recognize that the enrollment requirement for I-SNPs, but why wouldn’t someone in an institution, say like Assisted Living, just continue with their MAPD. What is the benefit gain for I-SNPs?

    1. Hi Timothy, an MAPD is simply a Medicare Advantage prescription drug plan, which is included in Medicare Advantage coverage. An I-SNP refers to a whole Special Needs Medicare Advantage plan for individuals in institutions.

  5. I have Medicare and the Florida Gold card Medicaid. My DOB is 11/12/1971 and had a stroke. I have been approved for Medicare since 2017. I have a Medicare red white and blue card. I have =been told I am not eligible for dual Eligible SNP (D-SNP). I was approved for meeting a medical needs but they told me I have a $718 per month cost. My total Social Security income is $913 per month. I have no other income. Can you help me?

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