Medicare Special Needs Plan Requirements

If you have special needs, you may qualify for one of Medicare’s Special Needs Plans. There are three different types of Special Needs Plans, or SNPs. Unlike Original Medicare and other Medicare plans, these plans are not open to all Medicare beneficiaries. To enroll in one, you must meet its eligibility requirements.

What Are Medicare Advantage Special Needs Plans?

Medicare Special Needs Plans are a type of Medicare Advantage plan. However, while most Medicare Advantage plans are designed to meet the needs of all Medicare enrollees, Medicare Advantage Special Needs Plans are designed to provide the care to a targeted group of Medicare enrollees.

Medicare SNPs provide the same benefits that all Medicare Advantage plans are required to provide. Additionally, all Special Needs Plans provide coverage for prescription drugs. Special Needs Plans may also provide extra benefits that cater to the group they serve.

Special Needs Plans typically use a network, as do most Medicare Advantage plans. However, because the plans are designed for specific groups, the network should include the types of specialists that group is likely to need. 

Enrollees in Special Needs Plans may need to select a primary doctor and get referrals to see specialists. There may also be a care coordinator who helps make sure the enrollees receive the care and information they need. 

Requirements for Joining a Special Needs Plan

Before you can join a Medicare Special Needs Plan, three things must be true.

First, you must be enrolled in Medicare. You cannot join a Medicare Special Needs Plan unless you have both Medicare Part A and Medicare Part B insurance coverage.

Second, you must meet the plan’s eligibility requirements. Special Needs Plans are not open to all Medicare enrollees, and you cannot join a plan unless you meet certain criteria. The criteria will vary depending on the type of Special Needs Plan.

Third, you must live in the Special Needs Plan’s service area. As with other Medicare Advantage plans, the availability of Special Needs Plans varies from region to region. However, the number of Special Needs Plans has been increasing in recent years. This means it is becoming more and more likely that there will be a plan that caters to your needs. Even if you could not find a suitable plan in past years, you may be able to find one now, so it’s worth looking again. 

The Three Types of Special Needs Plans

There are three types of Special Needs Plans:

1. Chronic Condition Special Needs Plans serve people with a specific severe or disabling chronic condition. 
2. Institutional Special Needs Plans serve people who live in an institution.
3. Dual Eligible Special Needs Plans serve people who are eligible for both Medicare and Medicaid. 

Requirements for Joining a Chronic Condition Special Needs Plan

Chronic Condition Special Needs Plans, or C-SNPs, serve Medicare enrollees with certain severe or disabling health conditions. Each plan focuses on a different chronic condition, so if you have a chronic condition, you should look for a plan that serves that specific condition. 

For example, if you have chronic heart failure, you could look for a C-SNP that caters to people with chronic heart failure. If you have a neurologic disorder, you could look for a C-SNP that caters to people with neurologic disorders. 

Other C-SNPs focus on; autoimmune disorders; cancer; cardiovascular disorders; chronic and disabling mental health conditions; chronic alcohol and other dependence; chronic lung disorders; dementia; diabetes; end-stage liver disease; end-stage renal disease; severe hematologic disorders; HIV or AIDS; and stroke.

Requirements for Joining an Institutional Special Needs Plan

Institutional Special Needs Plans, or I-SNPs, serve Medicare enrollees who live in an institution. For example, a Medicare enrollee who lives in a nursing home may qualify for enrollment in an Institutional Special Needs Plan.

Medicare enrollees who require nursing home care but live at home may also qualify for enrollment in an I-SNP.

Requirements for Joining a Dual Eligible Special Needs Plan

Dual Eligible Special Needs Plans, or D-SNPs, are designed for individuals who are eligible for both Medicare and Medicaid. 

• Medicare eligibility is usually based on age. Most people age into Medicare when they turn 65. Some younger people are also eligible for Medicare due to a disability or end-stage renal disease. Many people who qualify for Medicare also qualify for premium-free Medicare Part A coverage.
• Medicaid provides free or low-cost healthcare to qualifying individuals, and eligibility is based on income. Each state runs its own Medicaid program, so an individual will have to meet the eligibility requirements of the state where they live in order to enroll. If you think you might qualify for Medicaid, you can apply through the Health Insurance Marketplace or through your state’s Medicaid department. 

If you qualify for both Medicare and Medicaid, you can enroll in one of Medicare’s Dual Eligible Special Needs Plans, as long as there is one that serves your area. Enrollment in a D-SNP will help streamline coverage while ensuring that you receive all the benefits you are entitled to without paying more than you should. 

Joining and Leaving Medicare Special Needs Plans

Special Enrollment Periods allow individuals to enroll in Medicare or switch plans outside of the normal enrollment periods. If you qualify for a Special Needs Plan, you may also qualify for a Special Enrollment Period. 

Likewise, if you are enrolled in a Special Needs Plan and your situation changes so that you no longer meet the plan’s eligibility requirements, you will need to disenroll from the plan. You will be given a grace period of at least one month, possibly longer, to disenroll, and you will be given a Special Enrollment Period to select a different Medicare plan. 

Selecting the Right Medicare Plan for Your Special Needs

Medicare enrollees have many plans to choose from, including Medicare Advantage, Special Needs Plans, Medigap or Medicare Supplement Insurance, and Medicare Part D prescription drug coverage. Selecting the right plan can ensure that all of your health care and financial needs are met. If you need help choosing and enrolling in a Medicare plan, a licensed insurance agent can help you. Contact Legends to learn more.