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:
Illness SNPs (like End-Stage Renal Disease, HIV/AIDS, chronic heart failure, dementia, or diabetes),
- Dual Eligible or D-SNPs (for Medicare and
Medicaid beneficiaries), and
- Institutional 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
If I join an Special Needs Plan (SNP) can I get my health care from any doctor, other health care provider, or hospital?
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?
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?
What happens when I am in a SNP and no longer meet the plan requirements?
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.
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.
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