What is a Medicare Special Needs Plan (SNP)?

What is a Medicare Special Needs Plan?

A Special Needs Plan is a Medicare Advantage plan that provides benefits and services to people with specific severe and chronic diseases, certain health care needs, or who also have Medicaid. SNPs include care coordination services and tailor their benefits, provider choices and lists of covered drugs (formularies) to the groups they serve.

SNPs are either HMO or PPO plan types and cover the same Part A and Part B benefits that all Medicare Advantage plans cover. They might also cover extra services for the groups they serve: for example, Medicare.gov says an SNP may cover extra hospital days for someone with a severe condition like cancer or congestive heart failure. Rules and costs vary by plan.

Who can join a Special Needs Plan?

You can join an SNP if you have Medicare Part A and Part B, live in the plan's service area, and meet the eligibility rules for one of the three SNP types (or a subset of one of those groups):

A Dual Eligible SNP (D-SNP) is for people eligible for both Medicare and Medicaid; D-SNPs contract with the state Medicaid program to help coordinate Medicare and Medicaid benefits. An Institutional SNP (I-SNP) is for people who live, or are expected to live, for at least 90 days in a row in a facility like a nursing facility, skilled nursing facility, long-term care hospital, rehabilitation or psychiatric hospital, intermediate care facility or swing bed hospital, or who live in the community but need the level of care a facility offers. A Chronic Condition SNP (C-SNP) is for people with one or more of these severe or disabling chronic conditions, and a C-SNP can limit membership to a single condition or a group of related conditions:

• Cancer
• Certain autoimmune disorders
• Certain cardiovascular disorders
• Certain chronic and disabling mental health conditions
• Certain chronic gastrointestinal diseases
• Certain chronic lung disorders
• Certain neurological disorders
• Certain severe hematological disorders
• Chronic alcohol use disorder and other substance use disorders
• Chronic heart failure
• Chronic kidney disease and End-Stage Renal Disease (ESRD)
• Dementia
• Diabetes mellitus
• HIV/AIDS
• Stroke

What is an integrated D-SNP?

An integrated D-SNP is a single plan that combines your Medicare benefits with most or all of your Medicaid benefits and services. There are different types of integrated D-SNPs, but all of them must:

• Give you one member ID card that works for both Medicare and Medicaid
• Offer a single health risk assessment that covers both programs
• Provide a care coordinator or case manager to help manage your care and develop a personal care plan
• Have one process for appeals and complaints (grievances) about your Medicare or Medicaid coverage

When can I join or leave a Special Needs Plan?

If you qualify, you can join an SNP during the regular Medicare Advantage enrollment periods, such as the Open Enrollment Period from October 15 to December 7, and several Special Enrollment Periods apply to SNP members:

• Chronic condition: if a C-SNP serving your severe or disabling condition is available, you can join it anytime, but once you join, this Special Enrollment Period ends.
• Living in an institution: you can join, switch or drop a Medicare Advantage plan for as long as you live in an institution like a nursing home, and for 2 full months after the month you move out.
• Full Medicaid benefits: if you have Medicare and get full Medicaid benefits, you can join or switch to an integrated D-SNP, if one is available, once a calendar month, with the change taking effect the first day of the next month.
• No longer eligible: if you stop meeting an SNP's conditions, the plan notifies you and gives a grace period of at least one month. Your Special Enrollment Period starts with that notice, runs through the grace period and, if you're disenrolled at the end of the grace period, lasts 2 more months after your coverage ends.

How do networks, referrals and costs work in an SNP?

Networks, referrals and premiums vary by plan. Some SNPs require you to use providers in the plan's network (except for emergency care, out-of-area urgent care and out-of-area dialysis), and others cover out-of-network care, usually for more. An SNP that's an HMO generally needs a referral to see a specialist, while one that's a PPO doesn't; certain services, like yearly screening mammograms, don't require a referral.

Some SNPs charge a premium in addition to the Part B premium. If you have Medicare and Medicaid, Medicare.gov says most of the costs will be covered for you; your Medicaid office can tell you more. Like other Medicare Advantage plans, an SNP can't charge more than Original Medicare for certain services, like chemotherapy, dialysis and skilled nursing facility care. See how Medicare and Medicaid work together.