Special Needs Plans Offer Medicare Coverage Assistance


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What are Medicare Special Needs Plans (SNP)?

Medicare Special Needs Plans, or SNPs, are a type of Medicare Advantage Plan for those who meet certain conditions. They generally provide coverage for doctor visits, hospital services, and prescription drugs. To qualify for a Special Needs Plan, you must first have Original Medicare (Part A and Part B) and you must live within the service area of a Medicare SNP plan.

All Medicare SNP plans will have a provider network (just like any other plan). That means that you must visit a doctor, pharmacy, and hospital that is in your plan’s network. You will also have to select either a primary care physician or a health coordinator. The only exception is if you have End-Stage Renal Disease and need to see an out-of-network specialist for dialysis or if you have an urgent medical emergency and need to get to the nearest emergency room or urgent care facility.

There are three main types of special needs plans: CSNP, ISNP and DSNP.

Dual Eligible Special Needs Plan (DSNP)

If you are eligible for both Medicare and Medicaid, you can enroll in a DSNP. In this case, most of your costs will be covered for you. There are several Medicaid eligibility categories that could place you in a DSNP plan (as long as you are eligible for Medicare):

Qualified Medicare Beneficiary without Medicaid (QMB)

You do not receive Medicaid but have an income at 100% of the federal poverty level and your assets total no more than twice the social security limit. Through the QMB program, Medicaid can pay your Medicare Part A and B premiums, deductibles, and coinsurance.

QMB+

You meet QMB eligibility but are also eligible for Medicaid benefits. Medicaid can pay your Medicare Part A and Part B premiums, deductibles, and coinsurance.

Specified Low-Income Medicare Beneficiary without Medicaid (SLMB Only)

Your income is between 100 and 120% of the federal poverty level and your assets total no more than twice the social security limit, but you are not eligible for Medicaid. Medicaid can pay your Medicare Part B premium.

Qualifying Individual (QI)

Your income is between 120 and 135% of the federal poverty level and your assets total no more than twice the social security limit.

Qualifying Disabled and Working Individual (QDWI)

You returned to work and lost your Medicare Part A benefits but are eligible to enroll now. Your income is no more than 200% of the federal poverty level and assets are no more than twice the social security limit. You are not eligible for Medicaid, but Medicaid will pay your Part A premium.

Other Full Benefit Dual Eligible (FBDE)

You do not meet the criteria for either QMB or SLMB but are eligible for Medicaid. You can receive a Medicare Advantage Special Needs Plan during any time of the year.

How to Qualify for both Medicare and Medicaid

You can qualify for both Medicare and Medicaid if you meet the Medicaid eligibility limits in your state (based on your health and finances) and:

  • Are aged 65 or older
  • Have ESRD (End-Stage Renal Disease)
  • Receive Social Security Disability Insurance for over 24 months

We are working hard to keep state-by-state Medicaid eligibility requirements updated on our site for you. Click here to find out more about Medicaid in your state.

Institutionalized Special Needs Plan (ISNP)

ISNPs are for those who live in an institution like a skilled-care facility or nursing home and for those who have a nurse helping at home.

Chronic Condition Special Needs Plan (CSNP)

Another type of Medicare SNP is CSNP. CSNPs are generally designed for specific types of illnesses and disabilities. For example, a Chronic Condition Special Needs Plan for someone with chronic heart failure may provide extra coverage for heart treatments, while a CSNP for someone with chronic substance abuse may provide extra coverage for therapy and rehabilitation.

To qualify for a CSNP plan, you must have a qualifying disabling condition. Medicare.gov lists qualifying conditions as:

  • Chronic alcohol or other substance abuse
  • Autoimmune disorders
  • Cancer and precancerous conditions
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes
  • ESRD (End-Stage Renal Disease) or End-Stage Liver Disease
  • Severe hematologic disorders
  • HIV/AIDS
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Neurological disorders
  • Stroke

How to Enroll in a Medicare Advantage Special Needs Plan

If there is a Medicare Advantage special needs plan available in your area and if you are eligible, you can enroll either:

  1. When you first become eligible for Medicare and Medicaid
  2. During the Annual Enrollment Period (from October 15 through December 7 of every year)
  3. During your Special Enrollment Period (if you have one)

Most people who are eligible for a special needs plan are also eligible for a special enrollment period. You may have a special enrollment period if you:

  • Are diagnosed with a chronic condition (in which case you are probably eligible for a CSNP)
  • You move into or out of a nursing home
  • You move into a new service area
  • Your plan leaves the program

The best way to enroll in a Medicare Advantage Special Needs Plan is by speaking with a licensed benefits advisor who can guide you through the process. There is no cost to you and never any obligation to enroll. If you’re interested in speaking with a Medicare Plan Finder benefits advisor, click to request Medicare information or call 833-438-3676.

Have questions? Ask a Benefits Advisor!