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Medicare Advantage Special Needs Plans

Medicare Advantage Special Needs Plans offer tailored plan options to Medicare beneficiaries with certain health issues. Those with Medicare and Medicaid are eligible for another type of Medicare Special Needs Plan. Just as all people have individual medical needs, not all health conditions are generic. You may find your medical needs can be quite complicated, this doesn’t mean your coverage should be too. A branch of Medicare Advantage plans known as Medicare Special Needs Plans (SNPs) may be able to further help with extra coverage options.

Types of Medicare Advantage Special Needs Plans

If any of these categories listed below apply to your situation, you may have exceptional health-care needs. Special Needs Plans give you tailored coverage.SNPs have three different categories for health coverage. Medicare SNPs limit membership to beneficiaries in one of the 3 plan types.

The 3 Types of Special Needs Plans include Chronic Condition SNP, Institutional SNP, and Dual-Eligible SNP. Most SNPs are Health Maintenance Organizations.

Chronic-Condition SNP (C-SNP)

Medicare beneficiaries who suffer from certain severe and/or disabling, incurable conditions.

Conditions include one or more of the following: cancer, dementia, diabetes, epilepsy, chronic heart failure, or HIV/AIDS.

Medicare Advantage Plans won’t allow enrollment for patients with end-stage renal disease (ESRD). But, if a plan specific to ESRD beneficiaries is in your area, you may be eligible to enroll.

Starting in 2021, Medicare Advantage plans will accept ESRD patients.

Institutional SNP (I-SNP)

For certain beneficiaries living in an institution like a nursing home. I-SNPs are also for those who need at-home health or nursing care with certain illnesses.

When applying for this type of coverage, you’ll need to include proof of institutionalization need 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 SNP (D-SNP)

Beneficiaries who have both Medicare and Medicaid coverage are known as “dual eligible”. D-SNPs provide coverage to these individuals who are eligible.

All levels of Medicaid beneficiaries will be eligible for this coverage.

Medicare Advantage SNP Coverage

Special needs plans have coverage focused on certain diseases or health issues. For instance, an SNP may be specific to the benefits provided for beneficiaries with heart issues.

SNP for heart patients can include: 

  • A large network of a cardiologist
  • Clinical case management programs designed to help beneficiaries
  • A custom drug formulary (list of covered medications) specific to treating patients with heart issues

Eligible beneficiaries who enroll in this plan will receive benefits and coverage customized to their health condition and specific treatment needs.

What are the Benefits of Medicare SNPs?

Many benefits come with Special Needs Plans for those eligible to enroll. Some plans offer extra coverage for routine vision, dental, and hearing care benefits.

SNPs have specific network providers who specialize in treating conditions. An SNP provider will have a specific formulary to accommodate the cost of prescribed drugs to treat your specific illness.

All health-care services and providers should be coordinated through your Special Needs Plan for you, to help you manage your condition better.

An SNP plan will replace your Original Medicare; although, Medicare Advantage Special Needs Plans do include Part D prescription drug coverage.

What are the Special Needs Plan Limitations?

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

Exceptions for care include; if a beneficiary suffers a sudden illness requiring the E.R. or urgent care services or if a beneficiary has End-Stage Renal Disease (ESRD) requiring dialysis out of the service area.

Beneficiaries are required to use an in-network Primary Care Physician or care coordinator to assist with health-care.

Referrals to see specialists in the SNPs 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.

Enrolling in a Medicare Advantage Special Needs Plan

Traditional Medicare beneficiaries may enroll in an SNP available in their service area. The first chance to enroll is during your Initial Enrollment Period.

Medicare recipients can also enroll in an SNP during the Annual Enrollment Period or the Open Enrollment Periods.

Additionally, beneficiaries are given one Special Election Period each year to change to a Medicare Advantage Special Needs Plan.

Cost of Medicare Advantage SNP

If you have both Medicare and Medicaid, your plan should not cost you anything. If you do not qualify for Medicaid, then the plan’s cost will vary depending on your situation and the plan you choose.

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.

Before filing an appeal: 

  1. Ask your health-care provider and/or supplier for any information that might help prove your case.
  2. If health status is a concern, request for a fast decision. Once the plan or doctor agrees, the plan then has 72 hours to decide.
  3. When you enroll in a Special Needs Plan, the plan must state (in writing) how to make an appeal. Once you’ve filed an appeal accordingly, your plan will look-over its original decision for dis-enrollment.
  4. 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.
  5. Beneficiaries receiving care in a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation center, you have the right to a ‘fast-track’ appeal.

How to Get Help Applying for Medicare Advantage Special Needs Plans

To be clear, SNPs must provide you all the coverage included under Original Medicare and include Part D Prescription Drugs.

Medicare Special Needs Plans offers extra coverage options to help the management of your specific circumstance or disease.

Special plans are not offered everywhere across the country. Check your service area for plan options or talk to one of our Medicare agents today by calling the number above or filling out our online rate form.

We can help find the right Medicare plan for you. For eligible beneficiaries, Special Needs Plans may free up some of your monthly expenses.

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Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.


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