Some people living with certain health conditions or diseases, or those with low incomes, may require targeted and additional healthcare assistance that specifically addresses their situation. Medicare Special Needs Plans (SNPs) may be a good option to meet that need. Here's what you need to know about SNPs.
Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS) for people 65 and older and some younger people with qualifying disabilities such as End-Stage Renal Disease and ALS are eligible for benefits.
Medicare has four parts:
While these parts do an excellent job of providing coverage for most people and their health issues, sometimes more coverage is required.
Medicare Special Needs Plans are Medicare Advantage Plans offered by private companies that the government pays to administer Medicare benefits. SNPs must offer the same coverage and protections as original Medicare, but they can do so with different rules, costs restrictions, and other additional benefits.
SNPs have benefits that cover special health care or financial needs.
There are four kinds of Special Needs Plans:
A Medicare SNP is a limited enrollment plan offered by an HMO, a PPO, or a local or regional preferred provider organization (LPPO or RPPO). Depending on the plan, you may need to see in-network providers, or you may have the option of going out of your network. Plan availability will depend on where you live.
All these plans offer prescription drug coverage, and some may offer other benefits such as dental, hearing, and vision care.
Medicare SNPs limit membership to patients with specific diseases or characteristics. For example, a C-SNP might provide tailored services for people with HIV-AIDS, dementia, stroke, and so forth.
Providers narrow down benefits, provider choices, and drug formularies to best meet the specialized needs of these individual groups. They also make specialists available in the diseases or conditions that affect their members.
In most cases, you must get care and services from your in-network Medicare SNP provider. There are exceptions if you need urgent or emergency care and need immediate attention.
Depending on the plan, you may be required to have a primary care doctor. Other plans will assign you a care coordinator to assist you with your health care needs. You'll have to get a referral to see a specialist in your SNP most of the time.
Insurance companies have the option of deciding where they want to do business, so each year, various types of Medicare SNP's may or may not be available in different parts of the country. Insurance companies can offer more than one plan in an area, or they have the flexibility of deciding that a plan will be available to everyone with Medicare in a particular state.
Other times, insurance companies that offer Medicare SNPs can decide to join or leave Medicare altogether.
The Medicare Improvements for Patients and Providers Act (MIPAA) requires all SNPs to provide the following services:
All SNPs are also required to have a Model of Care (MOC) in place. This is a documented plan that identifies and addresses members' unique needs in the plan’s population. That includes quality measurements, measurable goals, and health outcomes.
Each enrollee is assigned an interdisciplinary care team (ICT) to develop a care plan specific to each member based upon the assessment, member preferences, personal goals, and needs.
Chronic Condition SNP (C-SNP)
C-SNPs serve people with a severe or disabling long-term health problem. Some plans are available only for people with a single specific condition, such as ESRD or chronic heart failure, or a subset of those conditions. Also, the availability of C-SNPs varies from company to company, which is part of what you need to consider as you look for a plan.
There are 15 SNP-specific chronic conditions approved by CMS:
D-SNPs are for people how to have Medicare and Medicaid. These people are often referred to as dual-eligible.
A D-SNP is a Medicare Advantage plan that combines your Medicare Part A and Part B benefits and your Medicare Part D prescription drug coverage. In addition, you get extra support to help coordinate your D-SNP with your Medicaid plan.
This type of plan also provides beneficiaries with additional coverage not usually provided by Medicare or Medicaid. For example, these added benefits may include dental, vision, and hearing coverage, care coordination through a personal care coordinator, and a personal emergency response system (PERS). Enrollees may also get help with transportation assistance, tele-health options such as virtual medical visits with their doctor, credits to buy health products, and more.
Again, each D-SNP is different, so you'll need to pay close attention to precisely what's offered as you research various plans.
It’s crucial to note that a D-SNP does not replace a Medicaid plan or change Medicaid eligibility. D-SNP enrollees keep their same Medicaid plan and still get the same Medicaid benefits.
Another critical thing: you must receive Medicare Part A and Part B and full Medicaid benefits to qualify for a D-SNP. There is a distinction between "full dual-eligible" or "partial dual-eligible." Depending on their status, some people only receive partial Medicaid benefits.
If you’re not sure what level you receive, check with your state Medicaid office to verify.
I-SNPs and IE-SNPs are similar, so it's appropriate to look at them together.
I-SNPs are for people who live in a care facility like a nursing home or get nursing care at home. These plans are for people who have had, or are expected to need, for 90 days or longer, the level of services provided in one of the following:
IE-SNPs are for people who live in an assisted living facility and get the same kind of care as in a skilled nursing facility.
To enroll, a beneficiary must be enrolled in Medicare. A beneficiary may also have Medicaid coverage, but that is not required. Plan members may have multiple chronic conditions or be affected by language barriers, health literacy challenges, poor socioeconomic status, cultural barriers, limited resources, limited access to health resources, and caregiver limitations.
Also, enrollees may require more outreach and face-to-face visits, especially by an interdisciplinary care team (ICT).
You must currently be enrolled in Medicare Part A and Part B to join a SNP. You’ll still be required to pay your Part B premium, although some SNPs may cover some of those costs.
Eligibility partially depends on where you live as SNPs are not available everywhere. You can work with a broker or agent, call Medicare directly at 1-800-MEDICARE or reach out to your State Health Insurance Assistance Program (SHIP) to determine availability.
As a reminder, you can only join a Medicare SNP if you fit the specialized needs served by the plan. After you’re enrolled, the SNP will require periodic proof that you continue to meet the required criteria.
Eligible beneficiaries are enrolled by licensed agents that have completed additional training using CMS-approved materials and processes.
For C-SNPs, you must get your doctor's confirmation that you have the condition addressed by the SNP.
For I-SNPs, you must live for at least 90 days in a long-term care facility served by the SNP or meet your state’s guidelines for requiring a nursing home level of care for at least 90 days. You can still qualify for an I-SNP before you have received care for at least 90 days if you’ll likely need long-term care for at least 90 days.
For D-SNPs, you must verify that you have Medicaid. Other conditions may apply that would allow you to enroll during a Special Enrollment Period.
If you’re enrolled in a SNP but no longer meet eligibility requirements, the SNP may extend coverage if it seems likely that you’ll regain eligibility soon. This could be anywhere from 30 days to six months.
Like other Medicare Advantage plans, SNPs may charge a monthly premium for coverage. All plans set their deductibles, copayments, and other cost-sharing for services.
If you have Medicaid, you won’t pay deductibles and copays for services in your D-SNP’s network. You may have coverage for out-of-network care, but you may also pay higher amounts for that privilege.
All Medicare SNPs include prescription drug coverage, but most of the time you pay some form of copayment for your prescriptions.
If you have extremely limited resources and income, you may be able to tap into Medicare's Extra Help program to pay your prescription drug costs. If you qualify, you may be able to pay very little or nothing out of pocket.
If you have Medicare and Medicaid, you qualify for Extra Help automatically. Otherwise, you can apply for Extra Help at any time. There is no obligation or cost to do so.
You can apply by contacting Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also contact your State Medicaid office. After you apply, you will get a letter in the mail letting you know what to do next.
If your plan denies you benefits for any reason, you can file an appeal with your SNP. That includes a provider who won't pay for services, stops providing services, doesn't allow certain types of services, or limits a service you think should be covered or provided.
A Medicare SNP must tell you in writing how to appeal. After you file an appeal, the provider must review its original decision. If your appeal is still denied, it will be reviewed by an independent organization that works directly for Medicare. The plan will not be involved in this part of the appeal.
IMPORTANT: If you’re concerned that your health could be seriously compromised by waiting for a decision about service, ask your plan provider for a quick decision. They must give you a reply within 72 hours.
Medicare Special Needs Plans can be a big blessing for those who need additional help. But it’s not always easy to figure out if you qualify, what plans are available, and any other number of things related to these kinds of Medicare Advantage plans.
If you’re looking for answers, give us a call at 800-435-4765. We’re here and ready to help you.