Medicare for Disabilities


Special Needs Plans: Tailored Health Care Solutions

Special Needs Plans (SNPs) offer a focused approach to healthcare, catering to individuals with specific medical conditions, unique healthcare requirements, or those who are also beneficiaries of Medicaid. SNPs meticulously customize their benefits, provider selections, and covered drug lists (formularies) to precisely address the needs of the particular groups they serve.

SNPs can fall under Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) categories, providing coverage for the same Medicare Part A and Part B benefits as other Medicare Advantage Plans. However, SNPs often extend additional services to cater to their specialized groups. For instance, if you have a severe medical condition like cancer or congestive heart failure requiring a hospital stay, an SNP might cover extended days in the hospital. Continuous eligibility for an SNP hinges on maintaining the specific criteria stipulated by the plan.

Qualification for SNP Enrollment

You’re eligible to enroll in an SNP if you fulfill these prerequisites:

  1. Dual Eligible SNP (D-SNP)
  2. Chronic Condition SNP (C-SNP)
  3. Institutional SNP (I-SNP)

Geographic Availability of SNPs

Each year, different varieties of SNPs may be accessible in different geographical regions across the country. Insurance companies determine their operational areas, hence SNPs may not be universally available throughout the U.S.

Common Questions

Is there a monthly premium associated with these plans?

The premium structure varies based on the plan. Some may entail a premium alongside the monthly Part B (Medical Insurance) premium. However, if you hold both Medicare and Medicaid, the majority of costs are typically covered. For detailed information, contact your Medicaid office.

Do these plans incorporate Medicare drug coverage (Part D)?

Yes, all SNPs must include Medicare drug coverage (Part D).

Am I free to choose any Medicare-accepting doctor or hospital for covered services?

The protocol depends on the specific plan.

  • Certain SNPs mandate care and services to be sought from providers and facilities within the plan’s network (excluding emergency care, out-of-area urgent care, or out-of-area dialysis).
  • Some SNPs extend out-of-network coverage, allowing access to services from qualified providers or facilities outside the network, albeit at a usually higher cost.
Is selecting a primary care doctor obligatory?

The requirement varies among plans. If you have a preferred primary care doctor or provider, inquire if you can retain their services under the chosen plan.

Is a referral necessary to consult a specialist?

Referral criteria fluctuate according to the plan. Certain services might necessitate referrals while others may not.

Additional Insights to Consider
  • D-SNPs streamline the coordination of benefits between Medicare and Medicaid.
  • For those interested in I-SNPs and residing in a facility, it’s important to verify that the plan offers services in your living environment.
  • C-SNPs may restrict membership to a specific chronic condition or a group of related conditions.
  • All SNPs employ care coordinators to aid in maintaining your well-being and developing a personalized care plan.
  • Continuous enrollment in a Medicare SNP is contingent upon the continuation of the qualifying condition. If you’re no longer eligible for your existing plan due to changing circumstances, you might qualify for a Special Enrollment Period to transition to another plan. When is it feasible to switch plans?
  • Specific services like chemotherapy, dialysis, and skilled nursing facility care under your plan cannot incur costs exceeding those of Original Medicare.
  • If your treatment requires prior approval and such approval has been granted, it must remain valid for the duration of the medically necessary treatment. Additionally, the plan cannot mandate additional approvals for the same treatment. Upon transitioning to a new plan, you’re afforded a minimum of 90 days before new prior approval requirements apply to ongoing treatment.
  • For precise details, consult the plan that piques your interest.
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