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What is a Medicare Advantage Special Needs Plan (SNP) and can anyone join a SNP?

A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan (MAPD) with healthcare benefits, provider choices, and drug formularies (list of covered drugs) designed for people who meet certain health or personal requirements such as people suffering from a chronic condition or have limited income and assets or people living in a long-term care (LTC) facility.

And no, not everyone can join a SNP . . .

Usually anyone who has Medicare Part A and Medicare Part B  coverage can join a Medicare Advantage plan (MA or MAPD) if the person lives within the plan's service area (Zip Code area), and does not suffer from kidney-failure or End-Stage Renal Disease (ESRD).  However, you cannot join a Medicare Advantage SNP unless you also qualify for the plan’s “Special Need” (for instance, you suffer from the specified chronic illness, like ESRD or financial need).

More about SNPs . . .

SNPs are divided into three major types of special needs:
  • Chronic Illness (C-SNPs) -- like End-Stage Renal Disease, HIV/AIDS, chronic heart failure, dementia, or diabetes,
  • Dual Eligible (D-SNPs) -- for Medicare and Medicaid beneficiaries, and
  • Institutional (I-SNPs) -- for Nursing and Long Term Care (LTC) residents.
A Medicare Special Needs Plan, according to the Centers for Medicare and Medicaid (CMS) is defined as:
A special type of Medicare Advantage Plan that provides all Medicare Part A and Part B health care and services to people who can benefit the most from things like special care for chronic illnesses, care management of multiple diseases, and focused care management.

These Medicare Advantage plans [SNPs] may limit plan membership to:

  • people in certain institutions (like a nursing home [or LTC facility]),
  • people who are eligible for both Medicare and Medicaid, or
  • people with certain chronic or disabling conditions (such as diabetes).
Do SNPs offer Medicare Part D drug coverage?

Yes.  All Medicare Advantage SNPs must provide their plan Members with prescription drug coverage (MAPD).  The prescription drug coverage is often designed to meet the SNP's particular needs - such as providing for certain medications on the SNP's formulary - or the SNP may provide an additional formulary tier that includes specific medications for the SNP members, this tier is often titled: "select care drugs".

If I join an Special Needs Plan (SNP) can I get my health care from any doctor, other health care provider, or hospital?

No.  Since a SNP is a Medicare Advantage plan, you generally must get your healthcare and related services from doctors, other health care providers, or hospitals in the plan's network (except for emergency care, out-of-area urgent care, or out-of-area dialysis).

Do I need to choose a primary care doctor?

Generally, yes.

Do I have to get a referral to see a specialist?

In most cases, yes. However, certain healthcare services, like yearly screening mammograms or healthcare checkup, don't require a referral.

Are SNPs widely available across the country?
No.  Medicare Advantage SNPs are offered only on a limited county-by-county basis and, again, Medicare beneficiaries must meet the specific SNP requirements - and are often found in more densely populated areas.
Also the SNP "landscape" changes each year and your current SNP may not be available next year.
What happens when I am in a SNP and no longer meet the plan requirements?

Possible disenrollment.  People who qualify to enroll in a SNP can be disenrolled from the SNP if, during the plan year, they no longer meet the plan's requirements.  For instance, if a person in a Dual-Eligible SNP (D-SNP) begins to earn more money they might no longer meet the plan's financial requirements, they may be enrolled from the D-SNP - or if a person no longer suffers from a certain chronic condition, they can be disenrolled from the SNP.

The good news:  If you are disenrolled from a SNP, you will be provided a Special Enrollment Period allowing you the opportunity to join another Medicare Advantage plan or Medicare Part D plan.

What else do I need to know about this type of plan?

  • [As noted above, a SNP] must limit membership to these groups:

    1) people who live in certain institutions (like nursing homes) or who require nursing care at home, or

    2) people who are eligible for both Medicare and Medicaid, or

    3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia).
    Plans may further limit membership.

  • Plans will coordinate the services and providers you need to help you stay healthy and follow doctors' or other health care providers' orders.

  • Go to MA-Finder.com or Medicare.gov/find-a-plan to see if there are SNPs available in your area.

  • If you need more, check with the plan.  You can find the plan's member services telephone number by clicking on the "benefits & contact info" button on our MA-Finder.com.

(source: Medicare.gov)

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.