What Are Chronic Special Needs Plans?

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Medicare is a great program, designed to make health care affordable to millions of people across the nation. However, it is a bit one-size-fits-all, and it sometimes comes up short helping people with chronic illnesses. For those Americans with one or more chronic conditions (there are more than 21 million of them on Medicare), traditional Medicare misses the mark a bit. This is where Chronic Special Needs Plans (CSNPs) come into play. These specialized Medicare Advantage plans are designed to help people with chronic illness. The rest of this short guide is dedicated to explaining what these plans are, how they work, and how to get one.

How Do Chronic Special Needs Plans (CSNPs) Work?

CSNPs are one of three kinds of Special Needs Plans:

  • Dual Eligible Special Needs Plans (DSNPs)
  • Institutional Special Needs Plans (ISNPs)
  • Chronic Special Needs Plans (CSNPs)

These kinds of plans are designed to meet the specific needs of various groups of Medicare Beneficiaries. CSNPs are designed to help those Medicare beneficiaries with one or more chronic illness. 

Specifically, these plans are Medicare Advantage plans. Medicare Advantage plans are an alternative to Original Medicare. This means that when you enroll in a Medicare Advantage plan, you are electing to receive your Part A and B benefits (normally provided by Original Medicare) from a private insurance company. A Medicare Advantage plan is required by law to cover everything that Original Medicare (Parts A and B) cover, so you don’t have to worry about your Medicare Advantage plan not offering coverage as comprehensive as Original Medicare.

The nice thing about Medicare Advantage plans, though, is that they usually provide more benefits than Original Medicare. These are known as “Extra Benefits.” Extra Benefits are various coverages that are not available from Original Medicare. Common examples of Extra Benefits include:

  • Vision, hearing, and dental
  • Fitness benefits
  • Transportation to and from medical appointments
  • Additional acupuncture or chiropractic care beyond the scope of Original Medicare

These benefits are nice extras, especially if you wear eyeglasses or contact lenses, since Original Medicare provides no coverage for those. However, there are two particular features that really make Medicare Advantage plans attractive:

  • They all have an annual Out of Pocket Maximum (OOPM) amount
  • Many Medicare Advantage Plans offer Part D prescription drug coverage (these are called MAPD plans)

The Out of Pocket Maximum, in particular sets Medicare Advantage apart from Original Medicare. Under Original Medicare, there is no cap on your out of pocket costs; they are theoretically unlimited. Since this represents a potential financial danger, the OOPM offered by all Medicare Advantage plans is very attractive.

So, now we know that Chronic Special Needs Plans (CSNPs) are a type of Medicare Advantage plan that are designed to help people with chronic illness. Let’s talk about what kinds of chronic illnesses qualify for CSNP plans.

Health expert asking senior about chronic health problems that she has.
CMS sets the standards for what symptoms and diagnoses qualify a person for using a CSNP

Allowable Chronic Conditions

Since Medicare Advantage plans are regulated by the Centers for Medicare and Medicaid Services (CMS), any plan designed to be a CSNP has to meet certain CMS requirements. CMS maintains a list of allowable conditions. There are many different conditions, but here’s a sample of covered chronic illnesses:

  • Heart and/or cardiovascular illnesses
  • Diabetes
  • End Stage Renal Disease
  • Autoimmune disease
  • Chronic or disabling mental conditions

CMS sets the standards for what symptoms and diagnoses qualify a person for using a CSNP. It’s important to note that Medicare Advantage plan companies (insurance companies) are allowed to create CSNPs, but they aren’t required to. They can also choose which kinds of CSNPs they want to create. Medicare Advantage plan Sponsors tend to have only one or two different kinds of CSNPs in each market. Probably no insurance company has a CSNP for all listed chronic conditions.

CSNPs And Part D Drug Coverage

Remember how we said many Medicare Advantage plans offer Part D drug coverage? Well, it’s important to know that every Chronic Special Needs Plan must offer drug coverage. This makes sense, since people with chronic illnesses usually are on several maintenance medications. CSNPs can help with the cost of these by offering drug coverage.

Coordinated Care

Probably the most unique feature of Chronic Special Needs Plans is their coordinated care features. Since these plans cater to people with serious health conditions, CSNPs bring focused attention to their care. Every CSNP is required to have procedures and requirements in place to ensure effective coordination and management of the member’s health condition.

This coordination is carried out in a two-part process:

  • Health Risk Assessment (HRA), and
  • Individual Care Plan (ICP)

The assessment is designed to identify the physical, mental, and emotional state of the patient and identify any particular areas that need close monitoring. Based on the risk assessment, the care coordinator works with the patient to create the individual care plan. The care plan takes into account the goals of the patient and also identifies the specific tasks, services, and other care required to meet the goal.

Crucially, the ICP is shared with the patient’s Primary Care Provider (PCP) so that this important physician can integrate the ICP into their treatment of the patient. At the patient’s request, the ICP can also be shared with specialists, pharmacies, and other authorized providers, family members, or caretakers. The goal in all cases is to more effectively and efficiently treat a person with chronic illness.

Special Rules About Enrollment

There are two main differences in enrolment eligibility for CSNPs versus standard Medicare Advantage plans. For one thing, in order to enroll in a CSNP, you have to prove that you have the specific chronic condition the plan covers. Generally, you will need a certification form your Primary Care Provider, who will be asked to complete a form attesting to your diagnosis and condition.

Secondly, people who meet the conditions for enrollment into a Chronic Special Needs Plan have a one-time Special Enrollment Period (SEP) available. You can access this SEP when either of these are true:

  • You are diagnosed with a chronic illness for which there is a CSNP in your area, or
  • You already have the chronic illness and you desire to enroll in a plan that covers your illness (as long as you’re not already covered by another CSNP)

This SEP is used up as soon as you enroll in a CSNP, and your coverage will be effective on the first day of the month after you enroll. If for some reason you no longer have the chronic condition (like if you get a kidney transplant and you no longer have kidney disease), you’ll have access to another Special Enrollment Period to enroll in a standard, non-CSNP.

How To Find And Enroll In A Chronic Special Needs Plan

The best way to enroll in a CSNP is to work with an independent, licensed health insurance agent. An agent can help you compare plans from different insurance companies, and most importantly find one that will work with your doctors and medications. An agent can also help you enroll in the plan of your choice and provide ongoing support if you should need it.


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Justin Brock

President & CEO of Bobby Brock Insurance