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.
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), it will be organized around the guiding principle of meeting the special needs of the beneficiary.
The three categories of Medicare SNP are:
- 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
The individuals that fit into any of these three Medicare SNP categories benefit from the tailored approach offered by these plans. The plans may have assembled a unique network of caregivers that specialize in the care of their condition or may provide care coordination that focuses on their social needs.
Because Medicare SNP plans 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. We have put together this guide to provide you with information on those topics and many more.
What is a Medicare SNP Plan?
Medicare SNP plans are purchased through private health insurance companies that have contracted with and are approved by Medicare. Like other Medicare Advantage plans, they 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 SNP plans are also required to provide a Medicare Part D prescription plan. Enrollees continue to pay the premium for Medicare Part B, and may also have to pay an additional premium for the SNP plan, for copays and coinsurance, and for additional benefits such as vision, dental, hearing, and prescriptions.
What differentiates the SNP plans from other Medicare Advantage plans is that they are built around specific conditions or situations that require a targeted approach to care and coordination. There are three types of Medicare SNP plans:
- For those who have chronic conditions (Chronic Condition Special Needs Plans)
- For those who live in an institution (Institutional Special Needs Plans)
- For those who are eligible for both Medicare and Medicaid (Dual Eligible Special Needs Plans)
Medicare SNP plans meet their 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, and because of the unique nature of their qualifications, enrollment in a Medicare SNP program is available at any time, though they are not offered everywhere in the country.
Advantages of a Medicare SNP Plan
Because Medicare SNP plans are created with special needs in mind, they generally go beyond providing the same level of coverage as Original Medicare Parts A and B, offering benefits that are specifically tailored to their enrollees’ conditions or circumstances. The targeted services that are offered are formulated to complement the regimens and requirements of the beneficiaries. This both improves treatment and minimizes frustrations and costs that may be encountered in other Medicare Advantage plans that serve a more general patient population.
If you are in one of the categories for which a Medicare SNP exists, choosing this type of coverage means you will automatically have access to a Medicare Part D Prescription plan appropriate to your needs. The SNP plans often offer special services, including coordinators that make sure you can easily access care. They may provide additional benefits in anticipation of potential complications or requirements of your medical condition, such as special dietary programs, additional hospitalization days or skilled nursing care.
Disadvantages of a Medicare SNP Plan
Though Medicare SNP plans are designed to provide special services to those Medicare beneficiaries that need them, there are some drawbacks to the programs. The SNP plans frequently require their enrollees to see physicians and use providers that are part of pre-established networks, and this may preclude you from remaining with your existing physician. You also may need to get referrals to see specialists. The programs are not widely available, and those who believe they are qualified in the programs must meet specific SNP eligibility criteria. Beneficiaries may be disenrolled when their status changes and they no longer meet the criteria, and will then need to enroll in another plan. Though, if a beneficiary is disenrolled they will have a Special Enrollment Period to join another Medicare Advantage plan.
Who is eligible for a Medicare SNP Plan?
Anyone who is enrolled in Original Medicare Parts A and B, but each of the three types of Medicare SNP plans have their own specific criteria for eligibility, and applicants will need to provide proof that they meet those criteria in order to enroll, and then to periodically resubmit proof affirming that they 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. As a result 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 disenrollment later.
Institutional SNP (I-SNP)
To qualify for an Institutional Special Needs Plan, you must live in long-term care served by the SNP for a minimum of 90 days. To qualify, 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. It is important to note that if you are enrolled in a Medicare MSP (Medical Savings Plan) at the time that you apply for a Dual Eligible Special Needs Plan, you may find that the specific plan does not accept MSP beneficiaries to enroll. 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 Plan cost?
The costs of a Medicare Special Needs Plan will vary depending upon the plan. Though all must provide the same benefits that Original Medicare does, each plan offers its own unique benefits tailored to the special needs that they address. At a minimum, enrollees are required to pay for their monthly Medicare Part B premium and any monthly premium that the Medicare SNP charges for health insurance coverage and Medicare Part D prescription coverage. If the enrollee chooses to add in vision, dental, or hearing care there will be an additional premium for those benefits.
Additionally, enrollees in Medicare SNP are responsible for their own deductibles, copayments, and other cost-sharing for services until they meet the plan’s out-of-pocket maximums. Those who have Medicaid will have their deductibles, copayments, and Part B and D-SNP premiums covered by Medicaid as long as they see providers who accept both the D-SNP plan they have chosen and Medicaid.
How do I enroll in a Medicare SNP Plan?
Like all other Medicare Advantage plans, you must be enrolled in Parts A and B of Medicare and enroll during the Annual Enrollment Period (AEP) or change to a D-SNP during the Medicare Advantage Open Enrollment Period (MA-OEP).
Additionally, you may be eligible for a Special Enrollment Period for a Medicare Special Needs Plan if you qualify for these plans, either 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.
Enrollment is most easily accomplished by contacting Medicare directly or by applying online.
Who should get a Medicare SNP Plan?
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 their enrollees are likely to find themselves underserved, overwhelmed ,and frustrated within the parameters of a standard, generic Medicare Advantage plan, SNP plans are tailored to the likely treatments, medications, and care coordination needs of those who meet their eligibility criteria.