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, you must first have Original Medicare (Part A and Part B), and you must live within the service area of a Medicare SNP plan.
There are three main types of special needs plans: CSNP, ISNP, and DSNP. All types work almost the same way, but you will likely qualify for one of the three. All three types will include a provider network that you must stick to. 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 exceptions to this are that those with End-Stage Renal Disease can see out-of-network specialists for dialysis and those who have an urgent medical emergency can visit the nearest emergency room or urgent care facility.
Unless you qualify for additional assistance, your plan will most likely come with a premium. Depending on the plan, you may also have cost-sharing fees like co-payments, coinsurance, and deductibles. Typically, SNP costs are lower than those of regular Medicare Advantage plans. They truly are designed to save money for people with medical and financial needs. 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 Costs.
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:
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.
DSNPs are mostly for those who are not only eligible for Medicare but also have low enough income to qualify for Medicaid. In this case, most of your costs will be covered for you.
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.
ISNPs are for those who live in an institution for at least 90 days. Institution refers to skilled-care nursing facility or nursing homes, inpatient psychiatric facilities, facilities for the developmentally disabled, etc.
Another type of Medicare SNP is a CSNP. They 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 offer additional coverage for therapy and rehabilitation.
To qualify, you must have a qualifying disabling condition and you must already have Medicare parts A and B. If you do not qualify for Medicare A and B, you cannot enroll in a CSNP. Medicare.gov lists qualifying conditions as:
SPAP stands for “State Pharmaceutical Assistance Program.” People who qualify for Special Needs Plans may also be eligible for SPAP. SPAP is 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 this SPAP chart can tell you whether or not the program is available near you and how to enroll.
Qualifying for a Special Needs Plan means you automatically qualify for a Special Enrollment Period. This means that while most Medicare beneficiaries have to enroll in the fall during the Annual Enrollment Period, you are able to enroll in a Medicare Advantage Special Needs Plan during any time of the year.
The best way to enroll 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 here to send us a message or give us a call at 833-438-3676.
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