The Basics of Medicare Special Needs Plans (SNPs)
What is a Special Needs Plan?
Medicare Special Needs Plans (SNPs) are private companies paid by the federal government to administer Medicare benefits. SNPs are required to provide the same benefits, rights, and protections as Original Medicare but can have different rules, restrictions, and costs. Some SNPs may offer additional benefits above and beyond Original Medicare.
A Medicare beneficiary may join an SNP if they meet the specific requirements, as a Special Needs Plan is designed to meet specific care-related needs. Care and coverage coordination services that may not be offered by other types of Medicare Advantage (Part C) Plans could be offered by one of these three types of Special Needs Plans:
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C-SNPs (Chronic Condition SNPs) – Formulated for beneficiaries with chronic conditions. They serve beneficiaries with conditions like cancer, dementia, diabetes, HIV/AIDS, stroke, End-Stage Renal Disease (ESRD), and certain neurological conditions.
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I-SNPs (Institutional SNPs) – Are for beneficiaries who reside in an institution, like a nursing home, long-term care skilled nursing facility, intermediate care facility, or an assisted living facility.
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D-SNPs (Dual Eligible SNPs) – Are made specifically for dual eligible individuals (those enrolled in both Medicare and Medicaid). Learn the difference between Medicare and Medicaid here.
Depending on if a beneficiary’s SNP is an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization), they may have to use in-network providers to get coverage. Some SNPs may give the option of going out-of-network.
What Does an SNP Cost and What Can it Cover?
Medicare Special Needs Plans (SNPs) is required to provide the same benefits as Original Medicare to beneficiaries. Still, they can to implement their own rules, restrictions, and costs and offer additional benefits above what Original Medicare offers.
SNPs may charge monthly premiums in addition to the Part B premium. They can also determine their deductibles, co-payments, and other cost-sharing options. If you would like to learn more about getting help with Medicare costs, click here.
SNPs can cover the same Medicare services Medicare Advantage (Part C) Plans are required to cover and may also cover additional services to serve the groups they are tailored to, like extra days in the hospital, prescription drug coverage, transportation to health-related appointments, and more. SNPs will coordinate with a beneficiary’s Medicare and Medicaid benefits for those enrolled in D-SNPs.
Depending on the plan, an SNP may help a beneficiary in managing their care by giving access to a care manager. A care manager will assist a Medicare beneficiary with a needs assessment and provide supervision. SNPs will also coordinate a Medicare beneficiary’s Medicare and Medicaid benefits if enrolled in a D-SNP.
A beneficiary may be covered for care out-of-network depending on their plan, but they may be subject to higher costs for out-of-network services. A Medicare beneficiary should contact their plan before going to an out-of-network service provider to see if it will be covered. SNPs are prohibited from charging more than Original Medicare for specific care and services, like chemotherapy, dialysis, and care from a skilled nursing facility. Co-pays for other services, like home health, durable medical equipment, and inpatient hospital care can be higher through an SNP.
The federal government requires all SNPs to provide Medicare Part D Prescription Drug Plan coverage to their enrollees, and some may provide additional benefits beyond those offered by Original Medicare.
How can a Medicare Beneficiary Enroll in an SNP?
A Medicare beneficiary must qualify to enroll in an SNP by applying and proving they meet the SNPs eligibility requirements. Thereafter, a beneficiary will need to periodically prove they still are eligible for the SNP.
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C-SNP (Chronic Condition SNP) eligibility requirements:
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A beneficiary must produce a doctor’s note confirming they have the condition the SNP focuses on.
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A beneficiary may be enrolled in a C-SNP before their eligibility is confirmed. If the plan cannot verify eligibility by the end of the first month of coverage, the beneficiary will be disenrolled at the end of the month.
If disenrolled, the beneficiary will have a Special Enrollment Period to enroll in another plan. This Special Enrollment Period will start when the beneficiary is notified of their disenrollment and ends after two months.
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I-SNP (Institutional SNP) eligibility requirements:
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A beneficiary must either:
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Live in a long-term care facility, like a nursing home or Intermediate Care Facility, for at least 90 days.
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Or meet their state’s requirements for nursing home-level care for at least 90 days, regardless of whether the beneficiary lives at home, in an institution, or in another community setting.
A beneficiary may still be eligible for an I-SNP before receiving 90 days of care if it can be determined they will likely need care for at least 90 days.
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D-SNP (Dual Eligible SNP) eligibility requirements:
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A beneficiary must provide proof they have Medicaid by showing their Medicare card, a letter from Medicaid, or have the plan verify the enrollment status with Medicaid by filling out the plan’s enrollment form.
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Specific D-SNPs will only serve beneficiaries with both Medicare and Full Medicaid benefits. Those enrolled in a Medicare Saving Program (MSP) will not qualify for these plans and will need to find a different D-SNP serving people with MSPs and Medicaid.
A beneficiary may have a Special Enrollment Period to join an SNP if the beneficiary:
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Has both Medicare and Medicaid. The Special Enrollment Period will last as long as the beneficiary has Medicare and Medicaid.
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Has a severe, disabling, or chronic condition. The Special Enrollment Period will last as long as the beneficiary has the condition.
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Is entering an institution that will qualify them for an SNP, or develops a need for nursing home-level care. A beneficiary may enroll or disenroll from an I-SNP at any time.
Can a Beneficiary Loose SNP Eligibility?
If a beneficiary is enrolled in a Medicare Special Needs Plan but does not meet the eligibility requirements, in this case, the plan may continue to serve the beneficiary for a period if they will likely regain eligibility within the given timeframe. Different plans will have different timeframes beneficiaries can regain eligibility from 30 days to 6 months. Remember, if eligibility is not regained within the plan’s designated timeframe, the SNP will disenroll you from the plan.
A beneficiary should get a notification in the mail from their plan within 10 days of discovering that they are no longer eligible for the SNP. This notification will explain how long the beneficiary will have to regain eligibility and the disenrollment process if eligibility is not regained. If a Beneficiary remains ineligible, they will be sent a second notice informing them of their plan’s termination.
Important Questions beneficiaries Should have About Special Needs Plans
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Am I eligible for a Special Needs Plan?
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How does an SNP compare to my current coverage?
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What benefits does an SNP have that will help with my special needs?
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What coverage associated costs should I expect with an SNP?
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What providers are in-network?
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Does the plan cover services from out-of-network providers?
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Will I need to be referred to see a specialist?
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What accommodations does the SNP provide for people with disabilities?
If you would like to learn more about Special Enrollment Periods and their eligibility requirements, click here.
All Special Needs Plans (SNPs) are not available everywhere. To find out about SNPs in your area, contact 1-800-Medicare or the State Health Insurance Assistance Program (SHIP) to learn more.
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