Special Needs Plans are a very unique type of Medicare Advantage plan. They are only available to Medicare beneficiaries who have certain health issues. Also, individuals who are “dual-eligible,” meaning they are eligible for both Medicare and Medicaid, can enroll in a separate type of SNP.
Certain health issues can be complicated. SNPs were created to help simplify the treatment and financial coverage of those health issues.
There are three types of Special Needs Plans. We’ll briefly discuss each one. If you find yourself fitting into one of the three categories, an SNP may be a good option for your healthcare coverage.
The three types of Special Needs Plans are:
Most Special Needs Plans fall into a Health Maintenance Organization (HMO).
Special Needs Plans are beneficial because of the unique coverage they provide. They are tailored for the individuals that qualify for each type of plan.
For instance, one SNP may include specific coverage for individuals with heart issues. An SNP for this health condition may have a large network of cardiologists, clinical case management programs, and a custom drug formulary.
Individuals who enroll in an SNP will enjoy the benefits and coverage of a plan that has been customized to their unique health conditions and treatment needs. An SNP plan will always include prescription drug coverage, which is not always the case with other Medicare Advantage plans.
Overall, there are many benefits to Special Needs Plans. Benefits may include:
Like other Medicare Advantage plans, SNP plans offer the same coverage as Parts A and B of Original Medicare. However, since these plans are offered by private insurance companies, they will have their own costs, rules, and limitations. Limitations may include only receiving services from providers within the plan’s network.
This limitation will be lifted if an individual has a sudden illness that requires immediate attention and care in an emergency room setting. It also does not apply to individuals with ESRD who require dialysis treatment outside of the plan’s service area.
Otherwise, SNP policyholders must receive care from an in-network primary care physician or care coordinator. These two professionals will assist them with setting up treatment and services, and also provide them with referrals to specialists should they require one. The specialists will also need to be within the plan’s network.
Annual mammogram screenings, Pap tests, and pelvic exams do not require referrals.
Individuals who wish to enroll in a Special Needs Plan must first enroll in Parts A and B of Original Medicare. Of course, they must also have one of the conditions that are included ineligibility for an SNP plan and the plan must be available where they live.
The first opportunity to enroll in a Medicare Advantage SNP is during your Initial Enrollment Period. Individuals may also enroll during the Annual Enrollment Period, which occurs each fall. If your condition is disabling, it may be possible to enroll in a C-SNP at any time of year.
If at any point when you are enrolled in an SNP you become ineligible for the plan, you will be given a Special Enrollment Period, during which you can choose other coverage.
As with any other Medicare Advantage plan, an SNP must provide at least as much coverage as Medicare Parts A and B and prescription drug coverage. SNPs offer additional coverage options based on your specific medical circumstances.
Special Needs Plans are not available everywhere. You will have to check which plans are available in your area of residence to see if one is available to you. Or, you can call one of our licensed agents and they can help you search for an SNP plan or another plan that will fit your healthcare needs.
You may get a notice of disenrollment from your current SNP plan. If you do not agree with the terms dictating the disenrollment, you have the right to file an appeal. If the plan still disagrees, there will be an independent organization that looks over your case. These organizations are employed by the Medicare program, not the insurance company.
Before filing an appeal, you should ask your health care provider to provide any information that may help your case. In cases where your current health condition may be compromised, you can ask for a fast decision. This gives the plan 72 hours to decide on eligibility.
The plan will review its original decision to allow you into the plan. It will consider this decision during the appeal process.
If you are discharged from a hospital before you feel you are ready, you have the right to an immediate appeal and review. In this case, the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) will perform the review. While the case is being reviewed, the hospital must allow you to continue care there free of charge. The hospital may not force you to leave until the BFCC-QIO has made a decision.
Any SNP plan member who is receiving care from a skilled nursing facility, outpatient rehabilitation center, or home health agency has the right to fast-track their appeal.
When you first enroll in an SNP plan, the plan must provide details about how to file an appeal should you ever be involuntarily disenrolled from the plan.