What is a Special Needs Plan? It is a type of Medicare Advantage plan that only applies to people who meet the eligibility requirements. These plans include benefits which serve for the distinctive needs of the members.
Below are the three types of Special Needs Plans (SNPs):
- Institutional Special Needs Plans (I-SNP) If a beneficiary lives in an institution (e.g. nursing home) or needs nursing care at home. Then these plans will serve them.
- Dual-Eligible Special Needs Plans (D-SNP) If a beneficiary has both Medicare and Medicaid, then Dual Eligible Plans will serve them.
- Chronic-Condition Special Needs Plans (C-SNP) If a beneficiary has certain impairing chronic disabilities like HIV/AIDS, cancer, or chronic health failure. Then the Chronic-Condition plan will serve them. This plan may work on more than one chronic condition.
If you have a particular illness described above, then Special Needs Plans cover the prescription drugs necessary to treat your illness. They also provide a bigger network of health care providers who can treat your condition. So, if you fall into the categories above, a Special Needs Plan may be best to address your needs.
Are you eligible for a Medicare Advantage Special Needs Plan?
Below are the eligibility requirements you must match to enroll in a Medicare Special Needs Plan:
- Meet the eligibility requirements: Have Medicare and Medicaid; have the qualifying chronic conditions; live in an institution.
- Already enrolled in Medicare Part A and Part B
- Reside in the service area of the Special Needs Plan
You are generally not permitted to enroll in a Medicare Advantage plan if you have end-stage renal disease, with some exceptions. Yet, you still may be able to enroll if a specific Special Needs Plan is selecting people with end-stage renal disease.
What are the benefits associated with a Special Needs Plan?
Here is what a Medicare Advantage Special Needs Plan Covers:
- Medicare Part A (hospital services)
- Medicare Part B (medical health-care needs)
- Medicare Part D (prescription drugs)
This is all handled through the Special Needs Plan.
Medicare approves Special Needs Plans through private insurance companies. This is similar to other Medicare Advantage plans. It is the law to have the same level of coverage as Original Medicare (Part A and Part B), when you are in a Medicare Advantage plan. Where you live determines what your Medicare plan options and benefits are. You may also have additional benefits than what Original Medicare covers being in a Medicare Advantage plan
Here is what some Special Needs Plans include:
- Wellness programs to help you with dietary or lifestyle activities that may help better your condition.
- Care-coordination services to help you stick to your doctor’s treatment regimen and help you better understand your condition.
What may be included in a Chronic-Condition Special Needs Plan is:
- Prescription drugs necessary to treat your illness.
- Provider networks with hospitals and physicians that specialize in treating a specific condition.
Need help coordinating your Medicaid and Medicare benefits? There may be certain services that can help you if you’re enrolled in a Special Needs Plan for dual eligibles.
What kind of coverage will you get with The Special Needs Plan? The coverage in the Special Needs Plan includes Original Medicare (Part A and Part B) and Medicare Part D. The Special Needs Plan just offers additional coverage for your condition. That includes the treatment of a serious chronic illness, living in a nursing home, or coordinating your Medicare and Medicaid benefits.
What is the main difference between other types of Medicare Advantage plan and a Special Needs Plan? The key difference is that the Special Needs plan is required to cover prescription drugs. Depending on the plan, other Medicare Advantage plans may or may not include prescription drug coverage.
The amount you will pay for a Medicare Advantage Special Needs Plan
Below are what you must pay depending on the Special Needs Plan:
- Cost-sharing expenses like coinsurance, deductibles, or copayments.
- If your Special Needs Plan Needs it: Extra monthly premium for added benefits
- If your Special Needs Plan Needs it: Extra monthly premium for prescription drug coverage.
- Medicare Part B premium
- Monthly premium for your Special Needs Plan
*Please Consider: If you are eligible for both Medicaid and Medicare (dual eligibility), and you have a Special Needs Plan. Then your cost-sharing requirements can’t be higher than what you would usually pay in Medicaid or Original Medicare.
Depending on if you receive both Medicaid and Medicare benefits or if you qualify for state financial assistance, your costs may vary. The kind of health care services you need and how often you must have it will determine your out-of-pocket costs. If you study your Medicare Advantage Special Needs Plan, you will see the amount you will have to pay as each Special Needs Plan is different. The cost sharing will differ when using the plan’s in-network providers in contrast to the out-of-network providers. That is, if the plan even let’s you see out-of-network providers.
How to get assistance with Special Needs Plans costs
Medicare might be able to cover some or all your Medicare Advantage SNP’s out-of-pocket or premiums costs under these conditions:
- If you have limited income
- Or if you have both Medicaid and Medicare
Check to see if you are eligible for a Medicare Savings Program. This can help you pay for costs like coinsurance, deductibles, copayments, or premiums. Eligibility is dependent on your income levels. For more information:
- Call 1–800-MEDICARE (TTY users 1–877–486–2048), open 24/7.
- Or contact your state’s Medicaid office for more information
How to enroll in a Medicare Advantage Special Needs Plan
Before you enroll in a Special Needs Plan you need to make sure:
- That you meet the eligibility requirements of that plan
- And if there is a Special Needs Plan in your service area
Then once these requirements are complete you can enroll in a SNP when you’re first eligible for Medicare.
Below are the timelines of when people are first eligible for Medicare so they can enroll in a SNP:
- The Initial Enrollment Period is when most people are first eligible. This time span is a 7-month period that begins 3 months before your 65th birthday, also your birthday month, and ends 3 months later.
- If you are getting Railroad Retirement Board or Social Security Disability benefits, then you are eligible for Medicare. You can be under 65 in this and still get Medicare because of your disability. Your Initial Enrollment Period begins on the 22nd month that you get Railroad Retirement Board or Social Security and lasts 7-months.
You will also be able to sign up to a Special Needs Plan in the Annual Election Period. This time period runs each year and is from October 15 to December 7. This period allows you to enroll for a SNP for the first time, change plans, or disenroll from your plan.
Also, if you qualify, you can join a SNP with a Special Election Period. Here’s how you can qualify for a Special Election Period to sign up for a Special Needs Plan:
- Your Special Needs Plan leaves the Medicare Program: If this happens you become qualified to change your Special Needs Plan using a Special Election Period.
- A provider diagnosed you with a disabling or severe condition: You can enroll for a Chronic Condition Special Needs Plan at any time you feel like it. When you decide to enroll in a plan, that is when your Special Election Period ends.
- If you relocate outside of your Special Needs Plan’s area: From here you’ll either be automatically returned back to Original Medicare. Or you can change to a new plan using the Special Election Period.
- You qualify for Medicaid: You can sign up for a Medicare Special Needs Plan at any time if you have Medicaid or are newly eligible for Medicaid.
- You leave, currently live in, or move into a nursing home: If this is the case, then you can switch plans or enroll in a Special Needs Plan at any time.
Please note that if you do not meet the eligibility requirements of the Special Needs Plan, you will not become or remain enrolled. So, if conditions change and you can no longer meet the Special Needs Plans enrollment criteria. Then you will be able to use a Special Enrollment Period to change to return to Original Medicare or change to another Medicare Advantage Plan.
For instance, if you no longer have the illness / condition that got you in the Special Needs Plan. Then you will be dropped from the plan. A Special Election Period will be offered to you to return to Original Medicare or to enroll in a different Medicare Advantage Plan. Also, if you are in a Dual-Eligible SNP and lose your Medicaid eligibility, you may be able to make coverage changes. You can make these coverage changes if you qualify for a Special Election Period after you lose your Medicaid eligibility.
Please use the plan finder tool, which is on this page to see your Medicare plan options in your area. Keep in mind that Special Needs Plans are not obtainable everywhere in the U.S.