A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan for individuals with extra healthcare needs. You must prove that you qualify based on diagnosis or income.

Medicare Special Needs Plans (SNPs) offer additional coverage for those with extra healthcare needs. These plans include prescription drug coverage. Depending on your SNP type, your plan may also include additional medical services.

Read on to learn about Medicare SNPs and how they may be able to help you.

Medicare SNPs are a type of Medicare Advantage (Part C) plan created by Congress to help people with specific healthcare needs.

What is covered by a Medicare SNP?

A Medicare SNP includes all of the Medicare services under one program, offering:

The main difference between SNPs and other Medicare Advantage options is that SNPs offer extra services based on your unique healthcare needs. This may include an allowance for additional days in the hospital, a care management specialist, or other social services.

What types of SNPs are there?

Medicare groups SNPs by specific health needs. Here are the details of these plans:

Chronic Condition Special Needs Plans (C-SNPs)

C-SNPs are for people who have severe or disabling chronic conditions. If you have one of the following conditions, you may be eligible for this type of plan:

This category also covers several groups of chronic diseases, including:

Institutional Special Needs Plans (I-SNPs)

I-SNPs are for people who need to live in a medical institution for 90 days or more. These include:

  • long-term care facilities
  • skilled nursing facilities
  • long-term care nursing centers
  • intermediate care centers for people with intellectual disabilities
  • resident psychiatric facilities

Dual Eligible SNPs (D-SNPs)

D-SNPs are perhaps the most complex. They offer additional coverage to people eligible for both Medicare and Medicaid.

As of 2019, about 11 million Americans are eligible for both federal (Medicare) and state (Medicaid) healthcare plans. People in this group have special healthcare needs due to both their medical or mental health needs and their ability or inability to pay for their care.

As with any healthcare plan, SNPs have specific advantages and disadvantages to consider before enrolling.

Advantages of SNPs

Enrolling in an SNP has many advantages since it’s designed to help with your specific needs. Benefits may include:

  • Care coordination: You will have a care coordinator who may be your primary care physician or a healthcare team to oversee your medical care. They ensure you receive all the necessary treatments to manage your condition(s).
  • Prescription drug coverage: Since these plans include drug coverage, you won’t need to shop for a separate Part D plan.
  • Additional coverage: As with most Medicare Advantage plans, you’ll receive extra coverage not offered by Original Medicare. These often include vision, hearing, dental, and fitness services.
  • Low cost: The costs for these plans are usually pretty reasonable, especially if you qualify based on a low income. There are also limits on out-of-pocket costs, which Original Medicare does not have.

Disadvantages of SNPs

However, there are also some potential downsides to consider as well, including:

  • Availability: Not all types of SNPs are available in all areas. Additionally, you may have limited coverage options if you need care when traveling outside of the state where you live.
  • Limited provider options: With SNPs, you’ll have to stick with a network of providers decided by the insurance company offering your plan. This could mean your preferred doctor might not be covered if they are outside the plan’s network.
  • Referrals: You’ll also need to get a referral from your primary care physician to see a specialist. Some plans may require you to get preapproval from the insurance company beforehand.

Different plans offer different premium costs, and copays may vary from plan to plan. Before enrolling in an SNP, review the company’s plan materials and ask about out-of-pocket costs and limits you may expect to pay. SNPs cannot charge more than they do for other Medicare-approved services.

Help covering the cost of Medicare

Medicare offers programs to help cover your healthcare costs, and you may qualify for Medicare’s Extra Help Program to help with out-of-pocket prescription drug costs.

If you have Medicaid, the cost to join a Medicare plan will be paid for you. If you have Medicare alone, the SNP costs should be close to what you already pay under a Medicare Advantage plan.

Next, we’ll go over the basics of what you’ll need to qualify for each type of SNP.

  • C-SNP: If you are applying under the chronic disease program, you must provide a note from your doctor stating that you have one of the covered conditions.
  • I-SNP: For the institutional plan, you must live for at least 90 days in a long-term care facility covered by the program or meet your state’s requirements for needing higher-level care like nursing home services.
  • D-SNP: For the dual eligibility plan, you must prove that you have Medicaid by showing a card or letter from Medicaid.

When you can enroll

Automatic enrollment doesn’t occur with SNPs, and typically, you would join an SNP during set Medicare Advantage enrollment periods.

Special enrollment periods are also offered for various reasons, including:

  • changes in health conditions
  • employment status
  • where you live
  • your plan

Special enrollment is offered to anyone with Medicare and Medicaid who is enrolled in both programs. People who need to move to a higher level of care or into a nursing home and those with a disabling chronic illness can enroll in an SNP at any time.

Who is eligible for Medicare SNPs?

To be eligible for a Special Needs Plan, you must qualify for a C-SNP, I-SNP, or D-SNP and already be enrolled in Medicare Parts A and B or Part C.

In addition, you’ll need to qualify for a specific type of SNP based on the rules of that plan, such as having a medical diagnosis or a certain income level.

Medicare SNPs combine Medicare parts A, B, and D to provide comprehensive care with extra medical and social services.

Costs vary by plan, but premium assistance can help lower your expenses.

Medicare has specific enrollment periods, but the factors that make you eligible for an SNP often make you eligible for special enrollment periods, too.