A Medicare Advantage Special Needs Plans are for people who have certain characteristics or chronic conditions. These plans are designed to coordinate your healthcare and help you follow your doctors’ instructions.
You can only join a special needs plan if you fall into one of these groups:
- You are institutionalized or need long-term skilled nursing care
- You are eligible for both Medicare and Medicaid
- You have a “severe and chronic disabling condition.”
Medicare Coverage and Special Needs Plans
Like all Medicare Advantage plans, Special Needs Plans offer all the benefits of Medicare Parts A and B. Special Needs Plans are unique because everyone in the plan has the same situation or health condition.
This means that Special Needs Plans can tailor their benefits to the specific needs of the people enrolled. For example, plans may include the specialists or drugs you are most likely to need, additional benefits, or a case coordinator to help monitor your condition.
Special Needs Plans can be HMOs, PPOs or HMO point of service plans. They operate with a network of doctors and other healthcare providers. In general, you must use providers within the network, except for emergency or urgent care. In addition:
- All Special Needs Plans include prescription drug coverage.
- Usually, you must choose a primary care doctor or a care coordinator who will help organize your medical care.
- You will probably need a referral from your primary care doctor to see a specialist.
When looking for a Special Needs Plan, be sure your doctors or the facility where you or your loved one lives are within the plan’s network.
Eligibility for Medicare Advantage Special Needs Plans
To be eligible for a Special Needs Plan, you must be enrolled in Medicare Parts A (hospitalization) and B (medical) and live inside the plan’s service area. Insurance companies decide what plans to offer and where to offer them, so there may not be a special needs plan in your city or state.
You must also meet the plan’s eligibility requirements. If you lose your eligibility, you cannot remain in the plan, but you will be given a grace period and an opportunity to enroll in another type of Medicare plan.
Types of Medicare Advantage Special Needs Plans
There are three types of Special Needs Plans:
Chronic Condition Special Needs Plans
Chronic condition Special Needs Plans (C-SNPs) are for people who have chronic conditions that are life threatening or cause disabilities. The Centers for Medicare and Medicaid Services has a list of 15 chronic conditions that qualify for C-SNPs. They include:
- Certain autoimmune disorders, including rheumatoid arthritis
- Certain cardiovascular disorders, including coronary artery disease and cardiac arrhythmias
- Diabetes mellitus
- Certain chronic lung disorders, including asthma and emphysema
- Chronic and disabling mental health disorders such as bipolar disorder and schizophrenia
C-SNPs may target one condition or a group of conditions that are similar or commonly found together, such as diabetes mellitus and cardiovascular disorder.
Institutional Special Needs Plans
Institutional Special Needs Plans (I-SNPs) are only available to people who need services from a skilled nursing facility, long term care nursing facility, intermediate care facility for people with intellectual disabilities, or an inpatient psychiatric facility. To be eligible for an I-SNP, you must need these services for at least 90 days. You can also be eligible if you are receiving your nursing care at home instead of in a facility.
Dual Eligible Special Needs Plans
A Dual Eligible Special Needs Plan (D-SNP) serves people who are eligible for both Medicare and Medicaid. Medicaid is a state-run health insurance program for people whose income is below a certain level. When someone is eligible for both programs, the state covers some Medicare costs. All levels of Medicaid beneficiaries are eligible for these plans.
Cost of a Special Needs Plan
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.
Get Help Finding Medicare Coverage
MedicareFAQ can help you navigate the confusing world of Medicare and find you the best price on the coverage you want. Let us give you a free, no-obligation quote. Just call us or fill out our form.