What Are Medicare Special Needs Plans (SNPs)?

Everything you need to know about Medicare Advantage Special Needs Plans (SNPs).
By Mike Parker
Updated Aug 2, 2022
A man with a Special Needs Plan on his way to a doctors appointment.
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Medicare Special Needs Plans (SNPs), are a type of Medicare Advantage plan that provides extra coverage to people who need it most. There are multiple types of SNPs out there and often it can be difficult to know which one is right for you.

In this article, we discuss what SNPs are, the different types, who should get them, and how much they cost.

A person with a disability.

Source: Unsplash

What Is a Medicare Advantage Special Needs Plan (SNP)?

Special needs plans (SNPs) are specifically designed to provide targeted care to people with special conditions or medical needs. These plans are offered by private healthcare providers and limit enrollment to special needs individuals. 

What Are Medicare Advantage Plans?

A Medicare Advantage plan, also known as Medicare Part C, is offered by private insurance companies and covers inpatient and outpatient treatment, items, and services. In some cases, it also covers Part D (prescription drug) costs.

SNPs are a type of Medicare Advantage plan that give members specialized hospital care, mental health services, rehabilitation services, and hospice care.

A special needs individual could be any one of the following:

  • An individual with a severe or disabling chronic condition: There are 15 SNP-specific chronic conditions, as outlined by the Centers for Medicare & Medicaid Services (CMS).

  • An institutionalized individual: A Medicare Advantage-eligible person who resides or is expected to stay in a long-term care facility for 90 days or more.

  • A dual-eligible individual: An individual who is enrolled in the federal Medicare program (Part A and/or Part B), as well as full-benefit Medicaid and/or a Medicare Savings Program (MSPs).

What Are the 15 SNP-specific Chronic Conditions?

  1. Autoimmune disorders.

  2. Cancer, excluding pre-cancer conditions or in situ status.

  3. Cardiovascular disorders.

  4. Chronic alcohol and other drug dependence.

  5. Chronic and disabling mental health conditions.

  6. Chronic heart failure.

  7. Chronic lung disorders.

  8. Dementia.

  9. Diabetes mellitus.

  10. End-stage liver disease.

  11. End-stage renal disease (ESRD) requiring dialysis.

  12. HIV/AIDS.

  13. Neurologic disorders.

  14. Severe hematological disorders.

  15. Stroke.

What Is Covered by a Medicare SNP?

A Medicare SNP is a different type of Medicare Advantage plan (Part C), which the US government started to help people with special types of health problems. 

Hospitalization (Part A), outpatient care (Part B), and prescription drug coverage (Part D), are all part of SNPs.

This type of plan will cover your doctor's visits, hospital stays, medication, and possibly other needs that an individual with a particular disease, disability, or condition might have.

Most SNPs offer more patient-specific services than regular Medicare Advantage plans. These extra services may include:

  • An allowance for extra days in the hospital.

  • A care management specialist.

  • Other social services.

What Types of SNPs Are There?

SNPs are divided into three main groups based on specific health needs. Let’s have a look at how they differ:

Chronic Condition Special Needs Plans (C-SNPs)

C-SNPs cover people who have severe or disabling chronic conditions. It may be possible to get this kind of plan if you have one of the following:

  • Cancer.

  • Chronic heart failure.

  • Dementia.

  • Type-2 diabetes.

  • End-stage liver disease.

  • End-stage renal disease (ESRD).

  • HIV/AIDs.

  • A stroke.

  • Substance abuse.

A person with a Chronic Condition Special Needs Plans.

Source: Pexels

Chronic Condition SNPs also cover other groups of chronic diseases, such as:

Chronic Disease GroupExample of Disease in Group
Autoimmune disordersLupus; Rheumatoid arthritis
Cardiovascular diseaseCoronary artery disease; Peripheral vascular disease
Hematologic (blood) disordersPreleukemia; Hemophilia
Lung diseaseAsthma; Pneumonia
Mental health conditionsAnxiety; Depression
Neurological issuesEpilepsy; Alzheimer's

Institutional Special Needs Plans (I-SNPs)

I-SNPs are plans that cater to people who need care in a medical institution for more than 90 days.

A person with an Institutional Special Needs Plan.

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These institutions include:

  • Long-term care facilities: A facility that provides skilled nursing care to patients or residents in need of assistance with activities of daily living (ADLs).

What Are Activities of Daily Living (ADLs)?

There are five ADLs, namely:

  • Bathing: This includes personal hygiene and grooming.

  • Dressing: This includes dressing and undressing.

  • Transferring: This includes movement and mobility.

  • Toileting: This involves continence-related tasks, including control and hygiene.

  • Eating: This includes preparing food and feeding.

  • Skilled nursing facilities (SNF): An in-patient rehabilitation and medical treatment center staffed with trained medical professionals.

  • Long-term care nursing centers: Centers that provide long-term medical and personal care in a clinical setting.

  • Intermediate care centers for people with intellectual disabilities: Long-term support and service for people with intellectual disabilities or related problems.

  • Resident psychiatric facilities: Facilities that provide out-of-home psychiatric care to people in a non-hospital, highly structured setting.

Dual-Eligible SNPs (D-SNPs)

D-SNPs are Medicare Advantage Plans that cater to people who are eligible for Medicare and Medicaid.

According to a CMS’s 2018 annual report, between 2006 and 2018, the total number of dual-eligible people for Medicare and Medicaid rose from 8.6 to 12.2 million, with an average annual growth rate of 2.9%.

People in the dually-eligible group have unique healthcare needs because of their medical requirements and ability to pay for care.

Pros and Cons of Special Needs Plans

As with any health coverage, there are benefits and drawbacks to SNPs to think about before signing up.

Pros of SNPs

Because SNPs are designed to help with specific medical needs, they can offer some benefits, such as:

  • Prescription drug coverage: SNP members won't need to look for a separate Part D plan because their plan already offers prescription drug coverage.

  • Care coordination: SNP members usually have a person or group who will be in charge of their medical care. These trained health professionals make sure that members receive the medical treatments they need.

  • Lower costs: Most of the time, SNPs aren't very expensive. There are also limits to out-of-pocket costs, which Original Medicare doesn't have.

  • Extra coverage: Like most Medicare Advantage plans, SNPs offer extra benefits that Original Medicare doesn't. Common extra coverage includes: hearing, vision, dental, and fitness services.

Prescription Drugs.

Source: Unsplash

Cons of SNPs

However, there are also some possible downsides to think about, such as:

  • Limited provider options: SNP members have to make use of a network of healthcare providers chosen by their health plan. 

  • Referrals needed: If you need to see a specialist, you need to get a referral from your doctor. 

  • Availability: SNPs aren’t as widely available as other types of Medicare Advantage Plans Also, if you need help outside of your service area, you may have limited coverage.

What Do Medicare Advantage SNPs Cost?

SNPs have different premium costs and co-payments will vary from one plan to the next. The monthly cost of joining an SNP will depend on your location, the type of SNP, and the conditions that it covers.

Terms You Should Know:

Premium: A regular payment made to an insurance company in exchange for insurance coverage.

Co-payments: These are fixed amounts that you pay for services, tests, and items. For example, you might be charged a $15 co-payment if you visit the doctor.

Before you sign up for an SNP, check out the company's plan materials and ask about out-of-pocket costs and limits you can expect to pay. 

If you already have Original Medicare, SNP costs should be close to what you currently pay for that plan.

Who Is Eligible for Medicare SNPs?

Let’s go over everything you’ll need in order to qualify for each of the three SNPs:

Type of SNPRequirements for Eligibility
C-SNPYou will need to show that you have one of the CMS-approved conditions that are covered.
I-SNPYou must live or plan to live in a long-term care facility covered by the program for at least 90 days OR you must meet your state's requirements for needing more help, such as nursing home care.
D-SNPYou will have to prove that you are with Medicaid by showing an official card or letter.

Do Medicare SNPs Cover Services that Medicare Doesn’t Consider Medically Necessary?

When it comes to Medicare SNPs, the general rule is that they don't pay for things that aren't medically necessary under Medicare.

To get a service that isn't medically necessary, you might have to pay for it out-of-pocket. You can, however, appeal the plan's decision.

How to Appeal a Medicare SNP Coverage Decision

People who are enrolled in Original Medicare or a Medicare SNP have the right to appeal any decision about their Medicare-covered services or benefits.

Your Medicare SNP must tell you in writing how to appeal. The plan will review its original decision after you file your appeal.

If your plan doesn’t rule in your favor, your appeal will be reviewed by an independent organization that works for Medicare. Your plan’s membership materials should have all the details about your Medicare appeal rights.

You can ask the plan for a quick answer if you think your health could be in danger by waiting for a decision on a service. They have to answer you within 72 hours.

Where Are Medicare SNPs Offered?

Some Medicare SNPs may be available in different parts of the country each year, but this changes annually. 

It's up to insurance companies to decide where they'll do business. Medicare SNPs may not be available in all parts of the country because of this.

Insurance companies can even decide whether a plan will be available to everyone in a state with Medicare, or only in certain counties.

These companies may also have more than one plan in a certain area, with different benefits and costs. There are a lot of insurance companies that offer Medicare SNPs and each year they can decide to join or leave Medicare.

What Is a Care Coordinator In a Medicare SNP?

Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. 

For example, a Medicare SNP for people with diabetes might use a care coordinator to help members do the following:

  • Monitor their blood sugar levels.

  • Follow what they eat and drink.

  • Get the right amount of exercise.

  • Schedule preventive services (such as eye and foot exams).

  • Get the right prescriptions to avoid problems.

What Is a Care Coordinator?

A care coordinator is someone who makes sure that people get the right care and information.

Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. However, not all Medicare SNPs have care coordinators.

A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members find community resources and make sure their Medicare and Medicaid services are all being used in the correct way.

When and How Can I Leave a Medicare SNP?

You can stay in a Medicare SNP only if you still have the special needs that the plan is meant to help with.

The grace period must be at least one month long, but plans can choose to give more time. A Special Enrollment Period will be available if you lose your eligibility for the plan. In this case, you can choose another plan.

When your Medicare SNP tells you that you're no longer eligible for the plan, that’s when the Special Enrollment Period starts for you. It will continue for two months after your insurance ends.

It's very important to review your current coverage options to make sure you don't lose the Medicare health and prescription drug coverage that you want to keep.

Example of How to Lose Access to Medicare SNP

You joined a Medicare SNP that only serves members with both Medicare and Medicaid, then you lose your Medicaid eligibility.

Medicare requires your plan to disenroll you unless you become eligible for Medicaid again within the plan's grace period.

Where Can I Learn More about Medicare and Health Cover?

Health insurance coverage can be very stressful and confusing, especially if you have special needs.

If you’re currently looking for a Medicare Advantage Special Needs Plan or are curious about which policy is best, get in touch with one of our professional consultants for tailored advice. Send us an email at help@policyscout.com or give us a call at 1-888-912-2132.

For more information, insurance quotes, and to get the process started, visit PolicyScout today.

A person with special needs.

Source: Unsplash