Medicare Special Needs Plans: Who Qualifies for One?

Medicare Special Needs Plans

Medicare Special Needs Plans are tailor-made for people who fit certain parameters, like having a chronic condition or qualifying for both Medicare and Medicaid.

When you are eligible for Medicare, you have a choice on how to receive your benefits. For example, you can enroll in Original Medicare Part A and Part B, or you can join a Part C Medicare Advantage plan. There are Medicare Supplement (Medigap) plans available to help fill the gaps in Medicare, and options for Part D prescription drug coverage.

There are also different types of plans. For example, Medicare Advantage plans have:

  • Health maintenance organization (HMO) plans
  • Preferred provider organization (PPO) plans
  • Private fee-for-service (PFFS) plans
  • Special needs plans (SNP)

The type of plan that's right for you depends on your circumstances, but if you have a specific disease, chronic condition, or characteristic, you may be eligible for an SNP.

Here is more information about what an SNP is, who is eligible, how much these plans cost, and how you can enroll to help determine what best meets your needs.

What is a Medicare Special Needs Plan?

A Medicare SNP is a type of Medicare Advantage (MA) plan, but limits its membership to people with specific diseases or characteristics. These plans tailor their benefits, provider choices, and drug formularies specifically for those they serve in order to best meet their needs.

Like other MA plans, SNPs are offered by private insurance companies and must be approved by Medicare. They must also offer everything Original Medicare does but may have different rules, restrictions, or costs. They may also provide additional benefits such as vision or hearing care, a larger network of specialized providers, or specific drug formularies.

Additionally, other than emergency or urgent care, you must typically get all your care and services from in-network doctors or hospitals. And, in most cases, you're required to have a primary care provider (PCP) or care coordinator to help with your care. This is especially important because you usually need a referral from your PCP or care coordinator to see a specialist.

Availability of plans can depend on where you live.

What is a care coordinator?

Some SNPs use a care coordinator to help you stay healthy and ensure you're following all doctor orders for your condition or situation.

For example, a care coordinator may help ensure you:

  • Eat a proper diet
  • Get exercise
  • Schedule preventive screenings for your condition
  • Are compliant with medications
  • Monitor your blood sugar, blood pressure, etc.

Care coordinators can also help ensure each of your doctors are up to date on your latest health information and work together to provide the best care.

If you're dual eligible, a care coordinator may help you access community resources and coordinate your Medicare and Medicaid services.

Types of Medicare Special Needs Plans

There are three types of SNPs, each with tailored services, providers, and drug coverage depending on the specific group they serve.

Dual Eligible Special Needs Plans (D-SNPs): For individuals with dual eligibility, meaning they are enrolled in both Medicare and Medicaid

Chronic Condition Special Needs Plans (C-SNPs): For those who have specific chronic conditions, such as one or more of the following:

  • Chronic alcohol and other dependence
  • Autoimmune disorders
  • Cancer
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-stage renal disease (requiring dialysis)
  • Severe hematologic disorders
  • Chronic lung disorders
  • Neurologic disorders
  • Chronic and disabling mental health conditions
  • Stroke

Institutional Special Needs Plans (I-SNPs): For people who live in an institution, such as a nursing home, long-term care skilled nursing facility, intermediate care facility, or assisted living facility

SNP plans limit their membership to one of these groups, or a subset of one of these groups, because they tailor their plans specifically for the group or subset.

For example, a C-SNP may be designed specifically for people with cardiovascular disorders. The plan's provider network would have specialists who only treat cardiovascular disorders, and the drug formulary would be designed to cover drugs used to treat those disorders. Members may also get benefits specifically tailored to their condition, such as case management programs or additional in-patient hospital coverage.

To learn what is and isn't covered by your plan and to ensure you're following the rules for coverage, contact your plan or read your plan documents carefully.

Who is eligible for a Medicare Special Needs Plan?

In addition to the requirements above, such as having dual eligibility, living in certain institutions, or having specific chronic conditions, you're able to join a SNP if:

  • You have Medicare Part A and Part B
  • You live in the plan's service area

You can stay enrolled in the plan as long as you continue to meet the conditions and requirements set. If you lose eligibility, you'll have a special enrollment period to decide how else you want to receive Medicare benefits and enroll in another option.

How much does a Medicare Special Needs Plan cost?

If you have dual eligibility and qualify for a D-SNP, most costs are covered for you.

Otherwise, your exact costs may vary by plan. What you pay out-of-pocket may be very similar to costs of other MA plans and could include a monthly premium, an annual deductible, co-pays, or co-insurance.

As with other MA plans, you must still pay your Medicare Part B monthly premium. You're also likely to pay less if you see an in-network provider for your care.

How to enroll in a Special Needs Plan

You're able to enroll in an SNP as soon as you're eligible for Medicare as long as there's an SNP plan in your area and you meet all eligibility requirements.

For most, this happens during their initial enrollment period (IEP), which is the seven-month period that begins three months before your 65th birthday, includes the month you turn 65, and ends three months later.

Or, if you qualify because of a disability, your IEP starts three months before the 25th month that you're receiving Social Security or Railroad Retirement Board (RRB) disability benefits and lasts for seven months. If you have ALS, it begins the month you begin receiving disability benefits.

Another time you can enroll is during the annual enrollment period (AEP), which is from October 15 through December 7 each year. 

Finally, if you qualify for a special election period, you can enroll in an SNP during that time.

To find an SNP in your area, use our Find a Plan tool or call us toll-free to talk to an experienced, licensed Medicare agent.

Additional Resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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