What Are Medicare Special Needs Plans?
A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage Plan that provides enhanced treatments to people who need targeted care. Three different types of SNPs can offer a coordinated care plan for those who need it. The targeted populations include:
- An institutionalized individual
- A dual-eligible (qualifies for both Medicare and Medicaid)
- An individual with a severe or disabling chronic condition, as specified by the Centers for Medicare & Medicaid Services (CMS)
First established in 2003, SNPs generally provide coverage for doctor visits, hospital services for people who have Original Medicare Part A and Part B, and live in the service area of a Medicare SNP plan.
Here’s what you need to know about SNPs:
How Medicare SNPs Work
Medicare SNPs are a type of Medicare Advantage Plan similar to an HMO or PPO. You will get care from providers in your SNP network (except if you need emergency care).
However, each SNP limits its membership to targeted and specific groups. For example, a Medicare SNP might be created to serve only people with cancer or congestive heart failure.
The plan would offer targeted access to providers who specialize in treating that particular condition. This would be augmented by drug formularies to include medications that also specifically address that condition.
In addition to covering all the things that Original Medicare covers, SNPs should be offered to provide services beyond that level of coverage, including specific health benefits and provider networks. This might mean lower cost-sharing, long covered benefit periods, additional wellness programs and preventative health benefit offerings, and more.
In many cases, SNPs use coordinated care providers to oversee your condition and make sure you see the right specialists and get the right information. For an SNP covering diabetes, this could mean the coordinator checks with a patient regularly to make sure they are following their diet, getting exercise, monitoring their blood sugar, and getting the right prescriptions to minimize complications.
If you don’t have a care coordinator, you will probably be required to choose a primary care doctor. The doctor or care coordinator will assist you with referrals to see a specialist in your SNP.
Every year, Medicare SNP providers drop in and out of the program. That means coverage could change from location to location and from year to year. Insurance companies decide where they will do business, so SNP coverage may not be available by some providers in all parts of the country. Insurance companies can also offer more than one plan in an area with different costs and coverages.
Also, you can only stay enrolled in an SNP as long as you meet the particular set of requirements for that plan. If you no longer qualify, you’ll have a short grace period to find a different form of coverage.
The Three Types of Special Needs Plans
There are three main types of Special Needs Plans:
Dual Eligible Special Needs Plans (DSNP)
DSNPs are mostly for those who are eligible for both Medicare and medical assistance from a state plan under Medicaid. Coverage and costs will vary from state to state. People who qualify for both are referred to as dual-eligibles.
It’s estimated that about 20% of Medicare beneficiaries are also eligible for Medicaid. When you have a claim, Medicare is the primary payer and Medicaid pays last.
You can either be eligible for full Medicaid or a Medicaid Savings Program (MSP) based on your income.
Since Medicare does not provide coverage for many types of long-term or custodial nursing home care, but Medicaid does, many low-income seniors are dual-eligible. Medicaid coverage for at-home care varies from state to state.
How to Qualify for Both Medicare and Medicaid
Eligibility for Medicaid is a means-based program determined on a state-by-state basis. The federal government determines Medicare eligibility. CMS administers both Medicare and Medicaid.
You can qualify for both Medicare and your state Medicaid program if you meet the Medicaid eligibility limits in your state (based on your health and finances) and you meet at least one of the following:
- You are 65 or older
- You have ESRD (End-Stage Renal Disease) or ALS
- You have received Social Security Disability Insurance for more than 24 months.
There is an overlap between the two programs. People generally qualify for Medicaid once they have exhausted their financial resources and can then meet strict income and asset limits. These people are known as full benefit dual-eligibles.
In other cases, a dual eligible beneficiary may be able to qualify for a Medicare Savings Program (MSP). These plans are offered by state Medicaid programs to help pay for some Medicare costs.
The MSPs are not as comprehensive as the combination of Medicare and full Medicaid, but they do offer attractive benefits and are less restrictive with higher asset and income limits.
People who qualify for an MSP are known as partial-benefit dual-eligibles.
Medicare Savings Programs for Dual Eligibles
You may qualify for one of the following MSPs:
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 Plus: 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.
CMS expects DSNPs to add value for the enrollees by augmenting or bridging a gap between Medicare and Medicaid covered services. CMS may approve flexible supplemental benefits that:
Are appropriate for individuals who need assistance with activities of daily living (ADL), including eating, drinking, dressing, bathing, grooming, toileting, transferring, and mobility.
Are appropriate for individuals who need assistance with instrumental activities of daily living (IADLs), including transportation, grocery shopping, preparing food, financial management, and medication management.
Do DSNPs Cover Dental Benefits?
Depending on the plan, a DSNP also covers a range of preventive services with no cost-sharing for a member. This may also include routine dental, routine vision, non-emergency medical transportation, and other related services.
Institutionalized Special Needs Plan (ISNP)
ISNPs are for those who live in an institution for at least 90 days or are expected to need a level or services provided by:
- a long-term care (LTC) skilled nursing facility (SNF)
- an LTC nursing facility (NF)
- an SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD)
- an inpatient psychiatric facility
Chronic Condition Special Needs Plan (CSNP)
CSNPs restrict enrollment to special needs patients with specific severe or disabling chronic conditions. A CSNP must offer services that go beyond basic Part A and Part B coverage.
About two-thirds of Medicare enrollees have multiple chronic conditions requiring coordinated care among primary providers, including:
- medical and mental health specialists
- inpatient and outpatient facilities
- extensive ancillary services related to diagnostic testing and therapeutic management
To qualify for a CSNP, you must have a qualifying disabling condition, and you must already have Medicare parts A and B. If you don’t qualify for Medicare A and B, you cannot enroll in a CSNP.
CMS has approved the following 15 specific chronic conditions that are eligible for CSNP coverage:
- Chronic alcohol and other drug dependencies
- Autoimmune disorders limited to polyarteritis nodosa, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, and systemic lupus erythematosus
- Cancer, excluding pre-cancer conditions or in-situ status
- Cardiovascular disorders limited to cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder
- Chronic heart failure
- Diabetes mellitus
- End-stage liver disease
- End-stage renal disease (ESRD) requiring dialysis
- Severe hematologic disorders limited to aplastic anemia, hemophilia, immune thrombocytopenic purpura, myelodysplastic syndrome, sickle-cell disease (excluding sickle-cell trait), and chronic venous thromboembolic disorder
- Chronic lung disorders limited to asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension
- Chronic and disabling mental health conditions limited to bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder
- Neurologic disorders limited to amyotrophic lateral sclerosis (ALS), epilepsy, extensive paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington’s disease, multiple sclerosis, Parkinson’s disease, polyneuropathy, spinal stenosis, and stroke-related neurologic deficit
These chronic conditions are reviewed periodically, and it’s best to check with CMS to see if health care research has demonstrated advancements in chronic condition management that may change the contents of this list.
Medicare Advantage providers are not allowed to enroll people with ESRD unless an SNP provider gets a waiver from CMS to open enrollment for people with ESRD.
The SNP provider must arrange access to services specifically targeted to people with ESRD, including nephrologists, hemodialysis centers, and renal transplant centers.
Benefits of a Medicare Special Needs Plan
SNPs are required to at least offer the same level of coverage as Medicare Part A and Part B. They must also offer prescription drug coverage as well. Many plans also offer enhanced benefits that provide additional coverage beyond Original Medicare.
With some SNPs, you will have a care coordinator who will provide you with a higher degree of personalized attention, helping you to stay focused on your treatment as dictated by your doctors.
SNPs also provide greater access to specialists who focus on the particular conditions of the SNP you enrolled in. The same goes for drug formularies, where certain SNP providers tailor drug offerings to meet the need for a particular condition best.
Many plans require that you use in-network providers, but some plans do offer the option of seeing doctors out-of-network as well.
Do All Medicare SNP Plans Have Drug Coverage?
By law, SNPs must follow existing Medicare Advantage program rules. This includes regulation 42 CFR 422 related to prescription drug plan program rules.
As such, all SNPs must provide Part D prescription drug coverage. This important provision is in place because special needs patients must have access to prescription drugs to manage and control their special health care needs. Unless there are provisions to the contrary, SNPs must abide by guidance in existing Part C and D rules.
Special Needs Plans Costs for 2020
Unless you qualify for financial assistance, your SNP plan may come with a premium cost in 2020. The exact cost will vary by the type of plan and provider you choose. Costs will be in addition to a Medicare Part B premium you will also need to pay.
You may also need to pay an extra monthly premium for prescription drug coverage and additional benefits.
Depending on the plan, you may also have cost-sharing fees like copayments, coinsurance, and deductibles. However, SNP costs are generally lower than those of regular Medicare Advantage plans. Also, you may need to pay more for out-of-network care, so it’s best to check with your plan before you see an out-of-network provider.
If you are in a DSNP, you won’t pay any more for your DSNP Medicare Advantage plan than you would with Medicaid. If you do have Medicaid, there is a chance that Medicaid will cover all of your DSNP Medicare Costs.
SNPs cannot charge more than Original Medicare for some types of care, such as chemotherapy and skilled nursing facility care. But they can charge more for other things such as home health or durable medical equipment.
Getting Help with Special Needs Plans Costs
Depending on your income and assets, and if you have Medicare and Medicaid, you may be able to get some or all of your costs covered through Medicaid. You may also qualify for a Medicare Savings Program to help pay for premiums, copayments, deductibles, and coinsurance.
To find out about getting help with SNP costs, call your state Medicaid office or call 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week.
Qualifying for the State Pharmaceutical Assistance Program
People who qualify for Special Needs Plans may also be eligible for the State Pharmaceutical Assistance Program (SPAP).
SPAPs are not available in every state, and every state program operates a little bit differently.
In some states, SPAP works with your Part D Medicare plan. In these cases, the program may be able to help you pay for your Part D premium, deductible, and copayments.
Enrollment is different in every state, but our SPAP chart can tell you whether or not the program is available near you and how to enroll.
Significant Changes in 2020 SNPs
About 13% of SNPs will be discontinued in 2020. But the offset of this is that overall, there will be a 19% increase in total nationwide coverage. Gains in other areas will offset SNP losses in some counties. Overall, there are more than 850 SNPs available in 2020, with the vast majority being DSNPs.
The highest concentration of SNP offerings is available in a few counties located in New York, Florida, and California.
The Bipartisan Budget Act of 2018 permanently reauthorizes SNPs as well as introduces further reforms aimed at cost-containment and improving quality.
There are also some changes related to quality control benchmarks that CSNPs and DSNPs must meet starting in 2020.
How and When to Enroll in a Special Needs Plan
Before you can enroll, you must meet eligibility requirements, which vary by the type of SNP.
CSNP eligibility requirements
You must get a doctor’s note from your doctor confirming you have the condition addressed by the SNP. The CSNP may enroll you before getting confirmation from your doctor, but confirmation must take place by the end of your first month. If not, you will be disenrolled from the plan at the end of the next month. You will have a Special Enrollment Period to enroll in a new plan if your existing plan disenrolls you.
ISNP eligibility requirements
You must live for at least 90 days in long-term care (LTC) facility that is served by the SNP (i.e., nursing home or an intermediate care facility for the mentally disabled). Or, you meet your state’s guidelines for requiring nursing home-level of care for at least 90 days, whether you live in an institution or a community setting (i.e., at home or in a group residence). You can still qualify for an ISNP if you haven’t received care for at least 90 days if it is likely that you will need long-term care for at least 90 days.
DSNP eligibility requirements
You must verify that you have Medicaid. Some DSNPs only serve beneficiaries with Medicare and full Medicaid benefits. If you’re enrolled in an MSP, you must find a plan that serves people with MSPs. If you meet the SNP’s eligibility requirements, you can join the plan during regular Medicare Advantage enrollment periods.
Qualifying for a Special Needs Plan means you automatically qualify for a Special Enrollment Period. You may be eligible for a Special Enrollment Period if you:
- Have Medicare and Medicaid. The Special Enrollment Period lasts as long as you have Medicare and Medicaid.
- Have a severe, disabling, or chronic condition. You can enroll in an SNP that serves that condition at any time.
- Are entering an institution that qualifies you for SNP coverage or develops the need for a nursing home-level of care. You can enroll in or disenroll from an ISNP at any time.
You can also enroll in an SNP during the Medicare Annual Election Period from October 15 to December 7 every year. During this period, you can enroll in an SNP for the first time, switch plans, or disenroll from your plan.
Once you have determined you meet eligibility requirements for an SNP, to enroll call Medicare at 1-800-633-4227, or the plan directly, or Medicare Plan Finder at 1-855-783-1189 (TTY 711).
The SNP will require periodic proof that you continue to meet these criteria.
What Happens If You No Longer Qualify for an SNP?
For a variety of reasons, a person enrolled in an SNP may become ineligible for the plan when they lose their special needs status because you no longer meet the special conditions served by the plan.
For example, with a DSNP, you may lose your Medicaid eligibility because you have gone over the assets and income limits. You would be forced to disenroll unless you become eligible for Medicaid again during the plan’s grace period. These grace periods are at least one month long but can be longer depending on the plan.
You will be eligible for a Special Enrollment Period if you lose your plan eligibility.
This Special Enrollment Period starts when your SNP notifies you that you’re no longer eligible for their plan. It continues during the grace period. If you’re disenrolled from the SNP at the end of the grace period, it continues for two months after your coverage ends.
Let Us Answer Your Questions About Special Needs Plans
Get your questions answered and see if you qualify to enroll by speaking with one of our licensed benefits advisors. We’re happy to guide you through the process.
There is no cost to you, and you’re never under any obligation to enroll.
To speak with one of our Medicare Plan Finder benefits advisors, send us a message or give us a call at 1-855-783-1189 (TTY 711).