How Do You Qualify for a Medicare Special Needs Plan?

Medicare SNP

Commonly referred to as an SNP, a Special Needs Plan is a type of Medicare Advantage (MA) plan designed for beneficiaries who meet certain criteria. These criteria differ based on the specific type of SNP. In addition, the SNPs themselves differ based on the specific needs of the people they serve and the insurance provider offering the plan. This post covers the basics of Medicare Special Needs Plans and answers common questions about them.

Medicare SNPs 101

Like any other MA plan, your SNP must provide all of the benefits you’re entitled to under Original Medicare (Parts A and B). Also like any other Medicare Advantage plan, your SNP may offer additional benefits. For example, all Special Needs Plans include prescription drug coverage.

Most SNPs resemble HMOs in that they require beneficiaries to receive care via the plan’s provider network. Exceptions are emergency care and End-Stage Renal Disease (ESRD) patients who require dialysis treatments outside of their service area.

SNP members typically need a referral from their primary physician to visit a specialist, with exemptions for certain services, such as yearly mammograms. To join an SNP, you must meet certain requirements (more on that in a moment). When you join, you should receive the assistance of a care coordinator to help you manage your heath.

What Are the SNP Requirements?

There are three different types of SNPs, with requirements varying according to the type. The most basic requirements – having Original Medicare and living in the plan’s service area – are true for all Special Needs Plans.

Medicare Special Needs Plan

A Chronic Condition Special Needs Plan (C-SNP) is for beneficiaries living with a severe or disabling chronic condition, such as cancer, dementia, and chronic heart failure. Many of these plans are specific to the type of condition, meaning you can’t necessarily join one simply because you have a chronic condition. This type of C-SNP would limit its network and drug formulary to the very specific needs of its population.

An Institutional Special Needs Plan (I-SNP) limits membership to beneficiaries who live in an institution or to those who receive nursing care at home. Finally, beneficiaries who qualify for both Medicare and Medicaid may join a Dual Eligible Special Needs Plan (D-SNP).

The insurance companies offering the SNP decide where to make the plan available and whether to offer more than one plan in an area. Plans may change from year to year, or the insurer may stop offering a plan entirely. To learn whether any Special Needs Plans are offered in your area, use the Medicare Plan Finder tool.

What Are the SNP Costs and Coverage?

SNP Costs and coverage vary according to the plan. However, all SNPs must provide at least the same coverage as Original Medicare, plus Part D drug coverage. Additional services vary by plan and even plan type. For example, a C-SNP plan may cover additional days as a hospital inpatient.

Costs within an SNP typically resemble those in any other Medicare Advantage plan. You have your usual Part B premium, but you may also have a small premium for your SNP. In addition, you likely have a small co-pay for services received. For D-SNP beneficiaries, most costs are covered by either Medicare or Medicaid.

What Does a Care Coordinator Do?

Offered by some SNPs, a care coordinator is exactly what it sounds like: someone who helps you coordinate and manage your healthcare needs. In a D-SNP, your care coordinator keeps you informed about the community resources available to you. He or she also ensures your providers all accept Medicare and Medicaid, coordinating your services between the two programs.

Medicare SNP

If you belong to a C-SNP and have a care coordinator, they might schedule common preventive services for your condition, such as eye and foot exams for diabetes patients. They also provide information intended to improve or manage your condition, such as diet and exercise guidance. Or, they may help manage your prescriptions to reduce the likelihood of complications or negative interactions between drugs.

Is it Always Better to Join an SNP?

The answer to this question varies according to your unique situation. As with any other Medicare plan, you need to compare your current coverage to what you would receive from the Special Needs Plan. Also, what special benefits does the SNP offer? If you have a chronic condition, you likely already have a care team. Does the C-SNP’s network cover them? If not, are you willing to change providers?

If you live in a nursing home and qualify for an I-SNP, will your level of care increase or improve? Is the home you currently live in part of the plan’s network? Other questions to ask (and answer) include:

  • Are your providers in the plan’s network?
  • Does the drug formulary include your prescriptions?
  • Is there a referral requirement for specialists?
  • Is there an annual out-of-pocket limit?

If you have any questions about SNPs or your other Medicare plan options, please call us toll-free at 844-655-4347. One of our licensed agents will answer any questions you have.

Kolt Legette

Kolt Legette

Licensed Insurance Agent at Medicare Solutions
Since 2015, Kolt Legette has helped clients navigate the often-confusing world of insurance. His number one goal is protecting the medical and financial wellbeing of every person he speaks with, whether they choose to buy insurance or not. Kolt loves representing the best brands in medical insurance as it allows him to provide side-by-side comparisons for his clients. This allows the client to decide which company works best for them. By putting the needs of the client above everything else, Kolt helps real people find affordable health insurance solutions for their most pressing healthcare needs. With his belief that peace of mind is priceless, Kolt's goal in every interaction is to make sure every person he speaks to leaves with the peace of mind they rightfully deserve.
Kolt Legette
Kolt Legette

Author: Kolt Legette

Since 2015, Kolt Legette has helped clients navigate the often-confusing world of insurance. His number one goal is protecting the medical and financial wellbeing of every person he speaks with, whether they choose to buy insurance or not. Kolt loves representing the best brands in medical insurance as it allows him to provide side-by-side comparisons for his clients. This allows the client to decide which company works best for them. By putting the needs of the client above everything else, Kolt helps real people find affordable health insurance solutions for their most pressing healthcare needs. With his belief that peace of mind is priceless, Kolt's goal in every interaction is to make sure every person he speaks to leaves with the peace of mind they rightfully deserve.

GET FREE MEDICARE PLAN QUOTES!