2022 Medicare Advantage Special Needs Plans Guide
Medicare Special Needs Plans (SNP) are coordinated care plans that offer targeted care to special needs individuals. SNP plans are managed through the Medicare Advantage program but have limited enrollment. To qualify as a special needs individual, you must meet one or more of the following criteria:
- An institutionalized individual,
- A Dual-eligible beneficiaries are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program.... (Medicare and Medicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States.) person, or
- An individual with a severe or disabling chronic condition.
An SNP can be any type of Medicare Advantage plan, including either a local or regional preferred provider organization (PPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan. However, SNPs are specific to the communities they serve:
- Chronic Condition SNP (C-SNP)
- Dual Eligibles SNP (D-SNP)
- Institutional SNP (I-SNP)
Special Needs Plans tailor their benefits, network, and drug A formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered. to best meet the needs of individuals with special needs. For this reason, all Medicare Advantage Special Needs Plans include a Part D drug plan.
How Do I Qualify for a Medicare Special Needs Plan?
About ten percent of all Medicare Advantage enrollees have a Special Needs Plan. Most people qualify to enroll in an SNP based on their financial situation (aka, dual eligibles) and/or a chronic health condition. Others qualify because they live in a nursing home or require skilled nursing care at home.
If you qualify for both Medicare and Medicaid, you can keep your Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. benefits and use Medicaid for your secondary coverage, or you can enroll in a Dual-Eligible Special Needs Plan (D-SNP).
The benefit of joining a Medicare D-SNP is that your complete breadth of coverage is coordinated by the plan and most of the costs will be covered for you. In fact, you can expect to pay little to nothing on A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., copays, and Coinsurance is a percentage of the total you are required to pay for a medical service. for Medicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Medicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. services covered by the plan. Many SNPs have a $0 monthly premium because your Medicaid benefits cover the premium for you.
Unfortunately, not all people who qualify can find a suitable SNP. Although the availability of SNPs is growing, plans are in short supply in rural areas.
To join a Medicare Advantage SNP, you must have both Medicare Part A and Part B. You also must live in the plan's service area. Then, you may be eligible if at least one of these conditions is true for you:
- You live in a nursing home or need skilled nursing care at home.
- You have one or more severe or disabling chronic conditions.
- You have both Medicare and Medicaid (dual-eligible).
The The Centers for Medicare & Medicaid Services (CMS) is the U.S. Federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs. (CMS) defines severe or disabling chronic conditions as follows:
- Chronic alcohol and other dependencies
- Autoimmune disorders
- Cancer (excluding pre-cancer conditions)
- Cardiovascular disorders
- Chronic heart failure
- Diabetes mellitus
- End-stage liver disease
- End-Stage Renal Disease (ESRD), also known as kidney failure, is a condition that causes you to need dialysis or a kidney transplant. People with ESRD are eligible for Medicare coverage regardless of age. (ESRD) requiring dialysis (any mode of dialysis)
- Severe hematologic disorders
- Chronic lung disorders
- Chronic and disabling mental health conditions
- Neurologic disorders
Before you can join a Chronic Illness SNP, your doctor must complete a chronic condition verification form at the time of your enrollment. Your insurance agent will provide you with the form and your doctor can complete and return it to verify your eligibility. For more information about qualifying chronic conditions, visit Medicare.gov.
Institutional Medicare SNPs (I-SNP) are similar to chronic illness plans, but they focus on providing coordinated care for people no longer able to live independently. To qualify, it is expected that the A person who has health care insurance through the Medicare or Medicaid programs. will live in the institution, or need at-home skilled nursing care, for at least 90 days.
What are the Benefits of a Medicare Special Needs Plan?
The goal of the A Special Needs Plan (SNP) is a type of Medicare Advantage plan that's available to beneficiaries with specific financial, health, or institutional needs. SNPs are regional, not available in all areas, and open to qualifying... initiative is to coordinate care. For this reason, these special plans combine hospital, medical, and prescription drug, and other benefits. Doing so makes it easier to coordinate care, makes it easier to follow the advice of your doctor and specialists, for things like diet and prescriptions, and can help you get assistance from the community. This happens because the entirety of your medical care is provided through a single plan.
Each Medicare SNP is designed for the community they serve. An SNP tailors benefits, doctors, drug coverage, and coordinators to meet specific needs. For instance, if you have diabetes mellitus, you'll need an SNP that offers special programs to manage care for people with insulin deficiency. It also might help you find the right specialist to treat your condition.
You also may have a care coordinator. This is most common if your SNP is for a chronic condition or because you are in an institution or receive home care. Your coordinator makes sure you get the care you need to get healthy and remain as healthy as possible. They also help you connect with various community services. If you are dual-eligible, a care coordinator may help you coordinate the benefits to help remove the complexity.
You won't need additional drug coverage. All Medicare SNPs include Medicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... drug coverage. That means you do not need a separate prescription drug plan, but you do need to verify that the SNP you choose covers your medications. This is particularly true if you have one or more chronic conditions.
How Do I Join a Medicare Special Needs Plan?
The first step is to find an SNP in your area.
- Use our Medicare Advantage Special Needs Plan Finder to quickly see the plans available in your area. Each plan in our SNP directory contains contact information. Look for "Contact the Plan" in the top matter.
- If you prefer, you can get help directly from Medicare by calling 1-800-MEDICARE (800-633-4227).
- You may also use the helpful resources at your local State Health Insurance Assistance Program (Scroll down and click on the "SHIP Locator" button). The people there can help find and join a Medicare SNP.
You'll need to complete an application form. You can ask the SNP to send you the proper form. Many SNPs offer online enrollment through their web site. If you're dual-eligible, you join through the Medicare.gov website.
When Can I Join a Medicare Special Needs Plan?
If you are joining Medicare for the first time, you can sign up during your first Medicare enrollment period. That is usually the month you turn 65 and the 3 months before and after that month.
If you already have Medicare, you can join during the next During the Medicare Open Enrollment Period, Medicare Advantage and Part D plan members can change, switch, or drop a plan they chose during the Annual Election Period. OEP starts on January 1 and ends on March 31.. Medicare's Annual Election Period (AEP) starts on 15 October and ends on 7 December.
Outside of these periods, you may be able to join a Special Needs Plan with a Special Election Period in certain situations. Some situations that may qualify you for a Special Election Period to enroll in a Special Needs Plan or make coverage changes include:
- You are diagnosed with a severe or disabling condition: You can enroll in a Chronic-Condition Special Needs Plan (C-SNP) for beneficiaries with your illness at any time.
- You move into a nursing home or require skilled nursing care at home: You can enroll in an Institution Special Needs Plan (I-SNP) or switch plans at any time.
- You qualify for Medicaid: If you have Medicaid or are newly eligible for Medicaid, you can enroll in a Dual-Eligible Medicare Special Needs Plan (D-SNP) at any time.
- You move outside of your existing Special Needs Plan’s service area: You'll qualify for a Special Election Period to switch to a new plan.
- Your Special Needs Plan leaves the Medicare program: You'll qualify for a Special Election Period to switch plans.
It's important to understand that you can only remain in an SNP for as long as you meet the eligibility criteria of that plan. If your situation changes and you no longer meet the requirements you’ll get a Special Election Period to switch to a different Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). or switch back to Original Medicare.
How Much Do Medicare Special Needs Plans Cost?
Depending on the plan, you will typically have the following costs:
- The Medicare Part B premium is the monthly charge paid by beneficiaries for their outpatient medical care, services, and supplies. A beneficiary's premium may be uplifted by an IRMAA surcharge if their income is above...
- The monthly premium for your Special Needs Plan
- The extra monthly premium for prescription drug coverage (if the SNP requires it)
- The extra monthly premium for additional benefits (if the SNP requires it)
- Cost-sharing expenses, such as A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., coinsurance, or deductibles
If you are dual-eligible, your Special Needs Plan can’t have higher cost-sharing requirements than you’d normally pay in Medicaid or Original Medicare. Also, Medicaid may be able to cover some or all of your A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. and/or Out-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments.. Depending on your income levels, you may qualify for a Medicare Savings Program (MSP) or Qualified Medicare Beneficiary (QMB) program, which can help pay for costs like premiums, copayments, coinsurance, or deductibles. Contact your state’s Medicaid office for more information, or call 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week.
It's important to keep in mind that costs will vary, depending on your qualifications for the various financial assistance programs. Medicaid is a state-run program and each state offers different benefits. Plus, our out-of-pocket costs will depend on the healthcare services you need and how often you use them. Each Special Needs Plan is different so you should review the Summary of Benefits document for the plan you’re considering. Make sure you pay careful attention to cost-sharing both Doctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... and out-of-network, as the cost differential can be significant.
What Questions Should I Ask?
Before joining a Special Needs Plan, consider getting the answers to these important questions:
- If dual-eligible, does the plan coordinate my Medicare and Medicaid benefits to make them easily accessible?
- If in a nursing home, does the plan's network include my nursing home?
- What costs should I expect for my coverage (premiums, deductibles, copayments)?
- Is there an annual limit on my out-of-pocket expenses?
- Will I be able to use my doctors? Are they in the plan's network?
- Are the plan's in-network providers and facilities in convenient locations?
- Does the plan provide coverage for services I receive from out-of-network providers?
- Do I need a referral to see a specialist?
- Are my medications on the plan's formulary?
- What special accommodations does the plan make for persons with disabilities?
- What special language and cultural accommodations does the plan make?
Each SNP has its own network of providers. In most cases, you will have to choose a primary care doctor. And in most cases, you will be required to use doctors, hospitals, and other providers in the network. Emergencies are an In a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... to this rule.
If you aren't happy with your SNP plan, you may switch to back to your Original Medicare benefits at any time. During the annual In health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions., you can choose another Medicare Advantage or SNP plan.
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