Medicare Advantage Special Needs Plans


Medicare Advantage Special Needs Plans offer tailored plan options to Medicare beneficiaries with certain health issues. Those with Medicare and Medicaid are eligible for another type of Medicare Special Needs Plan. Just as all people have individual medical needs, not all health conditions are generic. You may find your medical needs can be quite complicated but this doesn’t mean your coverage should be too. A branch of Medicare Advantage plans known as Medicare Special Needs Plans (SNPs) may be able to further help with extra coverage options.

Types of Medicare Advantage Special Needs Plans

If any of the below categories apply to your situation, you may have exceptional health care needs. Special Needs Plans give you tailored coverage. SNPs have three different categories for health coverage. Medicare SNPs limit membership to one of the three plan types.

The three types of Special Needs Plans include Chronic Condition SNP, Institutional SNP, and Dual-Eligible SNP. Most SNPs are Health Maintenance Organizations (HMOs).

Chronic-Condition SNP (C-SNP)

C-SNPs are for Medicare beneficiaries who suffer from certain severe and/or disabling, incurable conditions. Conditions include one or more of the following: cancer, dementia, diabetes, epilepsy, chronic heart failure, or HIV/AIDS. Starting in 2021, Advantage plans will accept ESRD patients.

Institutional SNP (I-SNP)

I-SNPs are for certain beneficiaries living in institutions such as nursing homes. I-SNPs are also for those who need at-home health or nursing care with certain illnesses.

When applying for this type of coverage, you’ll need to include proof of institutionalization need for at least 90 days. You could be eligible even if you’re receiving nursing care in a home instead of at a facility.

Dual-Eligible SNP (D-SNP)

Beneficiaries who have both Medicare and Medicaid coverage are dual-eligible. D-SNPs provide coverage to these individuals. All levels of Medicaid beneficiaries are eligible for this coverage.

Medicare Advantage SNP Coverage

Special needs plans have coverage focused on certain diseases or health issues. For instance, an SNP may be specific to the benefits provided for beneficiaries with heart issues.

SNPs for heart patients can include: 

  • Large networks of cardiologists
  • Clinical case management programs designed to help beneficiaries
  • A custom drug formulary (list of medications receiving coverage) specific to treating patients with heart issues

Eligible beneficiaries who enroll in these plans will receive benefits and coverage customized to their health condition and specific treatment needs.

Benefits of Medicare SNPs?

An SNP plan will replace your Original Medicare. Additionally, Medicare Advantage Special Needs Plans always include Part D prescription drug coverage.

What are the Special Needs Plan Limitations?

These policies must provide the same service options, coverage, benefits, protections, and rights that Original Medicare offers. However, SNPs may have different rules, costs, and restrictions. Restrictions may include receiving health care and services from providers within the SNP’s network.

Exceptions for care include if a beneficiary suffers a sudden illness requiring the E.R. or urgent care services or if a beneficiary has End-Stage Renal Disease (ESRD) requiring dialysis out of the service area.

These plans require beneficiaries to use an in-network primary care physician or care coordinator to assist with health care. Referrals to see specialists in the SNPs network are often required. On the other hand, some services or specialists don’t require referrals; specifically, annual mammogram screenings and pap tests/pelvic exams.

Enrolling in a Medicare Advantage Special Needs Plan

Traditional Medicare beneficiaries may enroll in an SNP available in their service area. The first chance to enroll is during your Initial Enrollment Period. Medicare recipients can also enroll in an SNP during the Annual Enrollment Period. If your condition is severely disabling, you can enroll in a C-SNP at any time. If you’re no longer eligible for the SNP, you’ll get a Special Enrollment Period during which you can obtain other coverage.

Cost of Medicare Advantage SNP

If you have both Medicare and Medicaid, your plan should not cost you anything. If you do not qualify for Medicaid, then the plan’s cost will vary depending on your situation and the plan you choose. Premiums can be as low as zero dollars and require no deductibles or copayments.

How Do You Appeal a Special Needs Plan Disenrollment Notice?

If you happen to get a notice of dis-enrollment, and you don’t agree with the terms – you have the right to file an appeal. Should your plan disagree with your appeal, an independent organization will look over the forms. These organizations work for Medicare, not for your SNP plan. So, no need to worry about a biased decision.

Before filing an appeal: 

  1. Ask your health care provider and/or supplier for any information that might help prove your case.
  2. If health status is a concern, request a fast decision. Once the plan or doctor agrees, the plan then has 72 hours to decide.
  3. When you enroll in a Special Needs Plan, the plan must state (in writing) how to make an appeal. Once you’ve filed an appeal accordingly, your plan will look over its original decision for dis-enrollment.
  4. If discharged from a hospital before ready, you have the right to an immediate review. The Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) does this review. While your case is under review, the hospital must allow you to stay free of charge. Prior to the BFCC-QIO’s decision, the hospital CANNOT force you to leave.
  5. Beneficiaries receiving care in a skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation center have the right to a fast-track appeal.

How to Get Help Applying for Medicare Advantage Special Needs Plans

To be clear, SNPs must provide all the coverage Original Medicare includes, as well as Part D prescription drug coverage. Medicare Special Needs Plans offer extra coverage options to help the management of your specific circumstance or disease.

Special Needs Plans are not offered everywhere. Check your service area for plan options or talk to one of our Medicare agents today by calling the number above. If you're not able to call now, fill out our online rate form.

We can help find the right Medicare plan for your needs. For eligible beneficiaries, Special Needs Plans may free up some monthly expenses.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

11 thoughts on “Medicare Advantage Special Needs Plans

  1. Hello! My mother has both Medicare & Medicaid in Ohio. Eventually her condition will be such that I will need to relocate her to Georgia. Is it possible that her eligibility will transfer, thou the Medicaid benefits could be different between the states? Have no idea how to approach this but got to start somewhere. Thank you!

    1. Medicaid benefits vary from state to state, however, Original Medicare benefits stay the same nationwide. If she has dual coverage in Ohio, she should qualify in Georgia as well, however income limits could vary. It would be best to start with calling the Georgia Medicaid office to receive information on income limits and if your mother would qualify.

  2. I am a 54 year old non-smoking disabled woman in upstate NY. Starting May 2022, I will receive SSDI at 1,989 per month and part B will be deducted automatically. I worked for 30 years, which, I believe, means there will be no deduction for part A. I live alone and 1,989 barely covers my rent and other needs, let alone taking 170 dollars out for part B. Do I qualify for any type of financial help? I spoke to Medicare and was told that Original Medicare is much better to use than a private insurance. I don’t think I can afford it and should probably let a private insurance handle everything including vision and dental. Do any of them help pay for the part B premium? I’m worried because I had a stroke and now live with sleep apnea, high blood pressure, diabetes and Graves disease, with monthly thyroid bloodwork checks, eye checks for thyroid and diabetes, CPAP equipment, and a lot of dental work in my future. It looks like I am not poor enough for Medicaid or Special Needs or Extra Help or any financial help. Do I have any options?

    1. Susan, it looks like your income would be over the limits for these programs. You should consider the deductible, copays, and coinsurances of an advantage plan before committing to advantage over a supplement. I recommend speaking to a licensed agent who can help you fully understand your available options.

    2. Susan, I have Humana Gold Choice SNP, special needs program because my income is low. From what I have been reading your diabetes and the cost of living in New York probably makes you eligible for their program if it’s in New York. I have been on disability for almost 20 years Other than 2 horrible years with another company, I have always had Humana plans.

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