Special Needs Plans are a type of Medicare Advantage plan that limits enrollment to Medicare beneficiaries who meet certain eligibility criteria. These plans cater their benefits to serve the unique needs of its members.
There are three types of Special Needs Plans (SNPs) available:
- Chronic-Condition Special Needs Plans (C-SNP): These plans serve beneficiaries with certain severe or disabling chronic conditions, such as cancer, chronic health failure, or HIV/AIDS. Chronic-Condition Special Needs Plans may target a single chronic condition or more than one condition.
- Institutional Special Needs Plans (I-SNP): These plans serve those living in an institution (such as a nursing home) or who need nursing care at home.
- Dual-Eligible Special Needs Plans (D-SNP): These plans serve people who have both Medicare and Medicaid benefits (also known as “dual eligibles”).
If you fall into any of these categories, you may have unique healthcare needs that a Special Needs Plan may be better equipped to address. For example, some Special Needs Plans offer a larger network of providers that specialize in treating your condition or have formularies that are tailored to cover the prescription drugs typically prescribed for your particular illness.
Eligibility for Special Needs Plans
To enroll in a Medicare Special Needs Plan, you must meet the following eligibility requirements:
- Be enrolled in Medicare Part A and Part B.
- Live in the service area of the Special Needs Plan.
- Meet the eligibility requirements that the Special Needs Plan targets (i.e., live in an institution; have Medicare and Medicaid; or have the chronic conditions(s) that the plan targets).
Medicare beneficiaries with end-stage renal disease are typically not allowed to enroll in a Medicare Advantage plan, with some exceptions. However, if there is a Special Needs Plan targeting end-stage renal disease beneficiaries in your service area, you may be eligible to enroll in this type of plan.
Medicare Advantage Special Needs Plans benefits
Medicare Advantage Special Needs Plans include coverage for hospital services (Medicare Part A), medical health-care needs (Medicare Part B), and prescription drugs (Medicare Part D) through a single plan.
Like other Medicare Advantage plans, Special Needs Plans are available through private insurance companies that are approved by Medicare. All Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B. Some Medicare Advantage plans may also cover benefits beyond what Original Medicare covers, and your Medicare plan options and benefits can vary, depending on where you live.
Some Special Needs Plans include care coordination services to help you better understand your condition and stick to your doctor’s treatment regimen. Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition. Chronic-Condition Special Needs Plans may include provider networks with physicians and hospitals that specialize in treating the specific condition of its members, or they may have formularies that are tailored to include the prescription drugs that treat that illness. If you’re enrolled in a Special Needs Plan for dual eligibles, there may be certain social services available to help you coordinate your Medicare and Medicaid benefits.
It’s important to note that you still get all the coverage that is otherwise included with Original Medicare, Part A and Part B, and Medicare Part D. The Special Needs Plan simply offers extra coverage to help you better manage your particular situation, whether that’s living in a nursing home; coordinating your Medicare and Medicaid benefits; or treating a serious chronic illness.
One key difference between a Special Needs Plan and other types of Medicare Advantage plans is that all Special Needs Plans must cover prescription drugs. In contrast, other Medicare Advantage plans (for example, HMOs and PPOs) may or may not include prescription drug coverage, depending on the specific plan.
Medicare Advantage Special Needs Plans costs
Depending on the Special Needs Plan, you will typically have the following costs:
- Medicare Part B premium
- Monthly premium for your Special Needs Plan
- Extra monthly premium for prescription drug coverage (if your SNP requires it)
- Extra monthly premium for additional benefits (if your SNP requires it)
- Cost-sharing expenses, such as copayments, coinsurance, or deductibles*
*Please note: If you are a dual eligible, your Special Needs Plan can’t have higher cost-sharing requirements than you’d normally pay in Medicaid or Original Medicare, Part A and Part B.
Keep in mind that your specific costs may vary, depending on if you qualify for state financial assistance or get both Medicare and Medicaid benefits. Your out-of-pocket costs will also depend on the type of health-care services you need and how often you need them. Each Special Needs Plan is different so you should review the specific Medicare Advantage SNP materials for the plan you’re considering to see exactly how much you’ll have to pay. Make sure you pay particular attention to the differences in your cost sharing when you use the plan’s in-network doctors versus out-of-network doctors (if the plan allows you to go outside the network).
Getting help with Special Needs Plans costs
If you have both Medicare and Medicaid or if you have limited income, Medicaid may be able to cover some or all of your Medicare Advantage Special Needs Plan’s premiums and/or out-of-pocket costs. Depending on your income levels, you may qualify for a Medicare Savings Program, which can help pay for costs like premiums, copayments, coinsurance, or deductibles.
Contact you state’s Medicaid office for more information, or call 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week.
Enrolling in a Medicare Advantage Special Needs Plan
You can enroll in a Special Needs Plan once you’re first eligible for Medicare if there is a Special Needs Plan in your service area for your target group and you meet the eligibility requirements of that plan.
Most people are first eligible for Medicare during their Initial Enrollment Period, the seven-month period that starts three months before your 65th birthday, includes your birthday month, and ends three months later. If you qualify for Medicare because of disability, your Initial Enrollment Period starts three months before the 25th month that you are receiving Social Security or Railroad Retirement Board disability benefits and lasts seven months.
You can also enroll in a Special Needs Plan during the Annual Election Period from October 15 to December 7 of every year. During this period, you can enroll in a Special Needs Plan for the first time, switch plans, or disenroll from your plan.
Outside of these periods, you may be able to join a Special Needs Plan with a Special Election Period in certain situations. Some situations that may qualify you for a Special Election Period to enroll in a Special Needs Plan or make coverage changes include:
- You are diagnosed with a severe or disabling condition: You can enroll in a Chronic-Condition Special Needs Plan for beneficiaries with your illness at any time, and your Special Election Period ends once you enroll in the plan.
- You move into, currently live in, or leave a nursing home: You can enroll in a Special Needs Plan or switch plans at any time.
- You qualify for Medicaid: If you have Medicaid or are newly eligible for Medicaid, you can enroll in a Medicare Special Needs Plan at any time.
- You move outside of your Special Needs Plan’s service area: You can use a Special Election Period to switch to a new plan, or you’ll be automatically returned to Original Medicare.
- Your Special Needs Plan leaves the Medicare program: You can use a Special Election Period to switch to a different Special Needs Plan.
Keep in mind that you can only remain enrolled in a Special Needs Plan for as long as you meet the eligibility criteria of that plan. If your situation changes and you no longer meet the enrollment requirements for the Special Needs Plan, you’ll get a Special Election Period to switch to a different Medicare Advantage plan or return to Original Medicare.
For example, if you’re in a Chronic-Condition Special Needs Plan and no longer have the condition that the Special Needs Plan targets, you’ll be disenrolled from the plan and given a Special Election Period to enroll in a different Medicare Advantage plan or return to Original Medicare. Similarly, if you lose your Medicaid eligibility and are enrolled in a Dual-Eligible Special Needs Plan, you may qualify for a Special Election Period to make coverage changes.