Ron Elledge is a seasoned Medicare consultant and author of “Medicare Made Easy.” As a Medicare expert, he regularly consults beneficiaries on Medicare rules, regulations, and strategies.
Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
Medicare Special Needs Plans (SNP) are versions of Medicare Advantage that have been created to accommodate three categories of enrollees who have unique needs. Whether the health insurance is structured as a Health Maintenance Organization (HMO) or as a Preferred Provider Organization (PPO), the network meets the specialized care needs of beneficiaries in the plan.
Because Medicare SNPs are meant to address specific needs, it is important that you fully understand the rules surrounding eligibility, what is offered, the costs, how to enroll, and more. Read this guide to learn more how Medicare SNPs work.
Who Should Get a Medicare SNP?
A Medicare SNP plan may be a good choice for you if you qualify, and if:
- You have a chronic health condition that requires multiple medications and frequent interventions from healthcare providers. You could benefit from targeted, coordinated care.
- You reside in a facility for at least 90 days because you need care that you cannot receive at home. You may receive additional coverage for skilled nursing services.
- You are eligible for Medicare and Medicaid. Your plan will make sure your providers accept Medicaid and will help coordinate payments.
What is a Medicare SNP?
A Medicare SNP (Special Needs Plan) is a type of Medicare Advantage Plan geared toward providing optimal care for specific categories of Medicare enrollees who have unique needs.
There are three types of Medicare SNPs:
- Chronic Condition SNP (C-SNP) – For those with specific chronic conditions such as HIV/AIDS, cancer, diabetes, certain neurologic disorders, dementia, stroke, or End-Stage Renal Disease (ESRD).
- Institutional SNP (I-SNP) – For those who live in a nursing home, long-term care skilled nursing facility, intermediate care facility or assisted living facility.
- Dual Eligible SNP (D-SNP) – For those who are dually eligible and enrolled in both Medicare and Medicaid.
|Plan structure||Special Needs Plans for specific populations. A type of Medicare Advantage Plan, but if you qualify, you can enroll anytime.|
|Benefits available||All Original Medicare benefits plus drug coverage and targeted care and care coordination. May offer vision, dental, or hearing for an additional premium.|
|Eligibility requirements||Must be enrolled in Medicare Parts A and B and have a chronic medical condition, reside long-term in an institution, or be eligible for Medicaid.|
Medicare SNPs meet enrollees’ needs in different ways. The C-SNP may offer formularies that specifically include medications that are commonly prescribed for their illness or a physician network that includes specialists in treating their condition. The I-SNP coverage may include more skilled nursing services, while dual eligible SNP enrollees may be provided with additional social services to help them coordinate payments and arrange for needed care.
The plans are only open to those who meet their eligibility requirements. Because of the unique nature of their qualifications, enrollment in a Medicare SNP is available at any time, though they are not offered everywhere in the country.
Benefits available with a SNP
Like other Medicare Advantage plans, SNPs include coverage for both Medicare Part A (hospital services) and Medicare Part B (medical services) at a level that is required to be at least the same as that offered by Original Medicare.
Medicare SNPs are also required to provide a Medicare Part D prescription drug plan. Enrollees continue to pay the premium for Medicare Part B, and may also have to pay an additional premium for the SNP, for copays and coinsurance, and for additional benefits such as vision, dental, hearing, and prescriptions.
|Advantages of a Medicare SNP||Disadvantages of a Medicare SNP|
Compare your Medicare options
See how a Medicare SNP compares to Original Medicare and other Medicare Advantage Plan types.
|Plan type||Costs*||Part A coverage||Part B coverage||Part D coverage||Out-of-state care**|
|Original Medicare||Part B premium||Yes||Yes||No||Yes|
|Medicare Advantage HMO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency only|
|Medicare Advantage PPO||Part B premium plus plan premium||Yes||Yes||Usually||Emergency, plus other care if in your plan’s network, or you pay more for out of network|
|Medicare Advantage PFFS||Part B premium plus plan premium||Yes||Yes||Sometimes||Emergency, plus other care if contracted with your plan and agrees to treat you|
|Medicare Advantage MSA||Part B premium plus high deductible||Yes||Yes||No||Emergency plus other care but you pay higher cost for out of network if your plan has a network|
|Medicare Advantage SNP||Part B premium||Yes||Yes||Yes||Emergency and out-of-area dialysis plus other care if in your plan’s network|
**Check with your plan for out-of-state coverage and service area.
Who is Eligible for a Medicare SNP?
You are eligible for a SNP plan if you are enrolled in Original Medicare Parts A and B and meet specific criteria for the plan you want to join. You will need to provide proof of eligibility initially and on an ongoing basis to show that you continue to qualify. The eligibility requirements for each type of SNP program are shown below:
Chronic Condition SNP (C-SNP)
To qualify for a Chronic Condition Special Needs Plan, an eligibility form will be sent to your doctor confirming your diagnosis with the condition covered by the SNP. Though you may enroll prior to the documentation being provided, if the SNP plan administrators are unable to verify that you meet the eligibility requirement by the end of the first month that you are enrolled, you will be disenrolled by the end of the first month. If that occurs, you will be entitled to a Special Enrollment Period that allows you to enroll in a new plan. The SEP begins when you are notified of disenrollment and ends two months after coverage ends.
Institutional SNP (I-SNP)
To qualify for an Institutional Special Needs Plan, you must live in a long-termin long-term care facility served by the SNP for a minimum of 90 days. The facility can be either a nursing home or an intermediate care facility for those with intellectual disabilities. Alternatively, you must have met your state’s guidelines for requiring a nursing home-level of care for a minimum of 90 days whether you live in a community setting such as your home or a group residence or in an institution. Those who have not yet received care for at least 90 days but who are likely to need that level of care for that period of time can also qualify.
Dual Eligible SNP (D-SNP)
To qualify for a Dual Eligible Special Needs Plan, you need to provide proof that you have Medicaid. This can be accomplished either by producing a letter from Medicaid or showing your Medicaid identification card. Alternatively, you can complete the enrollment form for the D-SNP and the plan administrator will verify your Medicaid status. If you are enrolled in a Medicare MSP (Medical Savings Program) at the time you apply for a Dual Eligible Special Needs Plan, you may find that the specific plan does not accept MSP beneficiaries. Most D-SNPs include a high level of dental, vision, and hearing care, as well as many other benefits.
How Much Does a Medicare SNP Cost?
Expect to pay your monthly Medicare Part B premium ($148.50 for 2021 for most people) and any monthly premium that the Medicare SNP charges for health insurance coverage and Medicare Part D prescription coverage. Some SNPs have a $0 monthly premium. If you choose to add vision, dental, or hearing care, there will be an additional premium.
As an enrollee in a Medicare SNP, you are responsible for deductibles, copayments, and other cost-sharing for services until you meet the plan’s out-of-pocket maximums. If you have Medicaid, it will pay your deductibles, copayments, and Part B and D-SNP premiums as long as you see providers who accept both the D-SNP plan you have chosen and Medicaid.
See how costs compare for these C-SNPs in Chicago, IL:
|Plan name||Monthly premium||Deductible||Copay||Coinsurance||Out-of-pocket max|
|Humana Community HMO Diabetes and Heart||$0||$0||PCP: $0
|25% for drugs when you reach the coverage gap||$2,600|
|Wellcare Speciality No Premium HMO||$0||$0||PCP: $0
|33% for specialty tier drugs||$3,450|
|Morecare+ HMO||$0||$0||PCP: $0
|25% for drugs when you reach the coverage gap||$3,450|
How Do I Enroll in a Medicare SNP?
Like all other Medicare Advantage plans, you must be enrolled in Parts A and B of Medicare and can enroll during the Annual Enrollment Period (AEP) or change to a SNP during the Medicare Advantage Open Enrollment Period (MA-OEP). However, because of the nature of SNPs, you can join a plan at any time if you qualify, by having both Medicare and Medicaid, having a severe, disabling or chronic condition, or by entering an institution or developing the need for nursing home-level of care for a period of or anticipated to be at least 90 days.
These are the enrollment periods for Medicare Advantage Plans. If you no longer qualify for a SNP and must enroll in another plan, you qualify for a Special Enrollment Period (SEP).
- Initial Enrollment Period (IEP): This seven-month period starts three months before the month of your 65th birthday, the month of your birthday, and ends three months after your birthday month.
- Initial Coverage Enrollment Period (ICEP): This is the enrollment period for those who want to enroll in a Medicare Advantage Plan and often occurs at the same time as the IEP for Original Medicare.
- Annual Enrollment Period: This period runs from October 15th through December 7th.
- Medicare Advantage Open Enrollment: Medicare beneficiaries who already enrolled in a Medicare Advantage Plan can switch plans between January 1st and March 31st.
Use the Medicare Plan finder to research available SNPs in your area. When you’ve chosen a plan, go to the insurer’s website to check for online enrollment options or contact the insurance company by phone or email to request a paper enrollment form. You can also enroll by calling Medicare at 1-800-633-4227.
To enroll, you need your Medicare number and the date your Parts A and B coverage began. Your Medicare card has this information.
Who Should Get a Medicare SNP?
Medicare SNPs are designed specifically for those who have chronic illnesses, are covered by both Medicare and Medicaid, or who are institutionalized. In addition to providing the same coverage that Original Medicare Parts A and B provide, they also meet the specific needs of those who qualify for their targeted coverage. Where you are likely to find yourself underserved, overwhelmed, and frustrated within the parameters of a standard, generic Medicare Advantage plan, SNPs are tailored to your likely treatments, medications, and care coordination needs if you meet eligibility criteria.