Navigating healthcare services can be daunting for anyone, especially those requiring extended medical benefits. Medicare Advantage offers Special Needs Plans for dual-eligible beneficiaries on both Medicare and Medicaid, and others experiencing chronic, institutional, or institutional-equivalent special needs.
What Is a Special Needs Plan (SNP)?
A Special Need Plan offers extra benefits to beneficiaries of Medicare Parts A, B, and D, including hospitalization, medical, and prescription drug coverage, respectively. The U.S. Congress first offered Special Needs Plans in 2006 to address the unique healthcare needs of chronically disabled, institutionalized, or dual-eligible Medicare beneficiaries.
What Do Special Needs Plans Cover?
Special Needs Plans cover Medicare Parts A, B, and D benefits all in one policy. SNPs expand on Medicare’s traditional hospitalization, routine medical, and prescription drug benefits, with extra coverage for unique benefits including working with a managed care specialist. Beneficiaries with chronic conditions such as diabetes may qualify for Special Needs Plans.
Medicare Advantage, also known as Medicare Part C, offers a variety of SNPs through private insurance providers. While Medicare Advantage plans offer additional benefits such as vision, dental, and hearing healthcare coverage, a Medicare Special Needs Plan also extends some aspects of parts A, B, and D to cover the unique needs of certain beneficiaries.
Types of Special Needs Plans
There are three main types of SNPs. Providers offer coverage based on who qualifies for Medicare Special Needs Plans, location, and availability.
Dual Eligible SNPs (D-SNPs)
Beneficiaries who qualify for both Medicare and state-funded Medicaid coverage may pursue a Dual Eligible Special Needs Plan, or D-SNP benefits. While D-SNPs offer the most comprehensive coverage of all SNPs, the requirements for this category are the most complex.
D-SNP applicants must require specialized mental or medical care and demonstrate financial need in order to receive both federal and state sponsored benefits.
Institutional SNPs (I-SNPs)
An Institutional Special Needs Plan, or I-SNP, suits Medicare beneficiaries that require long-term or resident care in a healthcare institution for at least 90 days. Examples include inpatient mental health rehabilitation, skilled nursing facilities, long-term nursing facilities, assisted living centers for the disabled, and residential psychiatric facilities.
This type of Medicare Special Needs Plan is ideal for beneficiaries living with a physical, intellectual, or behavioral disability that requires the ongoing intervention of healthcare professionals.
Chronic Condition SNPs (C-SNPs)
A Chronic Special Needs Plan, or C-SNP, tailors coverage to individuals who suffer from debilitating or acute chronic conditions. Eligible ailments include but are not limited to cancer, type-II diabetes, chronic heart failure, dementia, HIV/AIDS, or substance use disorder.
Beneficiaries may also qualify for C-SNP coverage for multiple or predisposition toward conditions under a broader group, such as cardiovascular disease, or blood, autoimmune, or mental health disorders.
Advantages and Disadvantages of Special Needs Plans
Though a specific set of criteria determines who qualifies for Medicare Special Needs Plans, beneficiaries may still experience pros and cons when selecting and using their benefits.
As a form of healthcare tailored to special needs, SNPs boast care coordination as a primary advantage. Beneficiaries enjoy the oversight of a dedicated care coordinator, such as a primary care physician (PCP) or team of PCPs, to coordinate all of their healthcare treatments. SNPs also automatically include Medicare Advantage benefits like vision, dental, and hearing services.
Additionally, the inclusion of prescription drug coverage eliminates the need to purchase a separate Medicare Part D plan. The relatively low cost of Special Needs Plans is also a plus, especially if you qualify for low-income status. Unlike original Medicare, SNPs also cap out-of-pocket costs for beneficiaries who have not yet met their annual deductible.
Special Needs Plans can also present some key disadvantages. As part of a Medicare Advantage plan through private insurers, SNP availability is limited by location and provider. Beneficiaries traveling out of state or outside of the U.S. may also experience limited coverage.
Beneficiaries who have established relationships with specific doctors may be at a disadvantage with a Special Needs Plan, which includes a limited provider network. Enrollees must visit in-network doctors, as determined by their SNP provider, to avoid out-of-pocket costs for care. Additionally, Medicare Special Needs Plans typically require referrals to see a specialist.
Cost of Special Needs Plans
While SNP costs tend to be higher than original Medicare alone, they are on par with Medicare Advantage plan expenses. Individual providers may set their own rates for SNP premiums and copays; however, these costs cannot exceed the provider’s rates for other Medicare-approved services. Qualifiers for both Medicare and Medicaid can receive help to pay premiums.
Eligibility and Enrolling in a Special Needs Plan
Individuals can join a Special Needs Plan during open enrollment for Medicare Advantage (January 1-March 31 annually). SNPs also offer extended special enrollment periods for reasons including changes to a beneficiary’s medical condition or their required level of care.
For example, special enrollment suits patients recently diagnosed with a chronic condition or moving into a nursing facility.
Dual Eligible SNPs require enrollees to verify that they receive both Medicare and Medicaid benefits. Beneficiaries can provide their Medicaid card or enrollment letter while completing the D-SNP application. Many D-SNPs will only enroll beneficiaries with full Medicare and Medicaid coverage, not those who only receive Medicare Savings Program benefits.
I-SNP candidates must reside in a long-term facility for a minimum of 90 days to enroll. Qualified facilities covered by I-SNPs include but are not limited to nursing homes and intermediate care centers for intellectually disabled individuals. Qualifiers may also include individuals who have not yet met the 90-day requirement but do meet their state’s requirements for long-term care.
Enrolling in a C-SNP requires candidates to obtain verification from their doctor of a chronic condition such as cancer, chronic heart failure, or end-stage renal disease. C-SNPs must provide confirmation from their doctor by the end of the first month of enrollment before they are disenrolled. C-SNPs offer a special enrollment period of two months for disenrolled candidates.