Special Needs Plans are a type of Medicare Advantage plan that coordinate care benefits (as CCPs) specifically to suit those with certain special needs. Membership is limited to those that meet specific criteria. The beneficiaries of these plans are institutionalized, dual eligible for Medicare and Medicaid, or suffering from a severe or disabling chronic medical condition. The three types of Special Needs Plans are Chronic Condition Special Needs Plans, Dual Eligible Special Needs Plans, and Institutional Special Needs Plans.
Special Needs Plans require that you get your care from providers within the network, except in the case of emergency care or if you have End-Stage Renal Disease, are out of state, and need dialysis. All SNPs provide prescription drug coverage. Many SNPs require that you have a primary care doctor or care coordinator. You have to receive a referral to see a specialist, except in cases where the service is covered as preventative, such as with yearly screening mammograms or pap tests performed in-network.
Chronic Condition SNP
A majority of medicare beneficiaries have two or more chronic conditions. However, these plans are restricted to specific severe or disabling chronic conditions. These individuals have comorbid or medically complex chronic conditions that are disabling or life threatening; this cohort of people also has a high risk of hospitalization or adverse health outcomes and require specialized care. Some of these conditions include cancer, dementia, End-Stage Renal Disease, HIV/AIDS, and amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease). There are fifteen conditions, some functioning as categories with multiple diagnoses such as cardiovascular disorders and chronic lung disorders. The latest panel held to update the list was during the fall of 2019.
Dual Eligible SNP
People who are members of D-SNPs are dually eligible for Medicare and Medicaid. There are multiple categories of Medicare eligibility, ranging from full Medicare eligibility to receiving aid as a Qualified Medicare Beneficiary (one of the Medicare Savings Programs). These plans have optional Medicare zero-dollar cost sharing.
I-SNPs are for individuals who have lived in a long-term skilled nursing facility, long-term care nursing facility, a combined skilled nursing facility/ nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility. They have to have resided in the facility for at least 90 days to enroll in this plan. The I-SNP will confirm that you are receiving an institutional level of care (LOC), as assessed by an independent, impartial party in order to enroll you.