Medicare Special Needs Plans

There are a variety of federal and state-run programs available to help Medicare beneficiaries with specialized health or financial needs. Some of these situations might include:

• High-risk groups of individuals having one or more severe or disabling chronic condition.
• Living in an institution.
• Being eligible for Medicaid.

If you’re a Medicare beneficiary with one of the above circumstances, you may not realize that there are Medicare plans available that are specifically designed to help you manage the complex health challenges that may come with your situation.

Special Needs Plans tailor their benefits and services for Medicare beneficiaries with unique health or situational challenges. Here’s an overview of how they work, including what they cover, eligibility, and how to enroll.

How Special Needs Plans work

Special Needs Plans (SNPs) are a type of Medicare Advantage plan for beneficiaries who meet certain eligibility criteria. Like other types of Medicare Advantage plans, these plans are available through Medicare-contracted private insurance companies. Each type of plan limits enrollment to the group that it targets, and there are three kinds:

• Chronic-Condition Special Needs Plans are for beneficiaries with severe or disabling chronic health conditions. There are 15 conditions approved by the Centers of Medicare & Medicaid Services (CMS) (see below for a full list).
• Institutional Special Needs Plans are for beneficiaries who live or are expected to live in an institution or require nursing care in their home for 90 days or more. This includes assisted living or nursing homes, long-term care skilled nursing facilities, inpatient psychiatric facilities, or intermediate care facilities for people with developmental disabilities. Enrollment of a special needs individual on the basis of the potential for a 90-day stay must be based on a CMS-approved assessment.
• Dual-Eligible Special Needs Plans are for beneficiaries who have both Medicare and Medicaid, also known as dual eligibles.

Like all Medicare Advantage plans, these plans must cover the same benefits as Original Medicare, Part A and Part B, with the exception of the hospice benefit (which is still covered under Original Medicare). Medicare Advantage Special Needs Plans may also include coverage beyond Part A and Part B, such as routine vision and dental, hearing services, or wellness programs. Unlike other types of Medicare Advantage plans that may or may not cover prescription drugs, these plans always include prescription drug coverage.

One notable difference between Special Needs Plans and other types of Medicare Advantage plans (such as HMOs or PPOs) is that each plan tailors its benefits, provider networks, and covered medications to serve the unique needs of its members. For example, a Chronic-Condition Special Needs Plan for cancer patients may include doctors and oncologists in its network who specialize in treating various types of cancer. A Dual-Eligible Special Needs Plan may cover care-coordination services that help members better manage their Medicare and Medicaid benefits.

Eligibility for a Special Needs Plan

To be eligible for a Medicare SNP, you must:

• Have Medicare Part A and Part B.
• Live in the service area of the plan.
• Meet the plan’s eligibility criteria (for example, have the chronic condition(s) that the plan targets).

You can only stay enrolled in the Special Needs Plan as long as you continue to meet the membership criteria. For example, if you enroll in a Dual-Eligible Special Needs Plan and then lose your Medicaid eligibility, you’ll get a Special Election Period to enroll in another type of Medicare Advantage plan (such as an HMO or PPO) or return to Original Medicare.

Chronic-Condition Special Needs Plans can target a single health condition or a group of conditions, such as stroke and cardiovascular disorders. For Chronic-Condition Special Needs Plans that target more than one health condition, prospective enrollees need to have at least one of the health conditions to be eligible to enroll. Medicare Advantage SNPs can target any of the following 15 conditions:

• Chronic dependency on alcohol or drugs
• Autoimmune disorders
• Cancer (with the exception of pre-cancer conditions)
• Cardiovascular disorders
• Chronic heart failure
• Dementia
• Diabetes mellitus
• End-stage liver disease
• End-stage renal disease that requires dialysis
• Severe hematologic disorders
• Human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)
• Chronic lung disorders
• Chronic and disabling mental health conditions
• Neurologic disorders
• Stroke

Enrolling in a Special Needs Plan

If you are a dual eligible or live in an institution, you can enroll in a Special Needs Plan or switch plans at any time with a Special Election Period.

Otherwise, you can enroll in a Special Needs Plan during your Initial Coverage Election Period, which is when you’re first eligible for Medicare Part C coverage. In most cases, this period takes place at the same time as your Initial Enrollment Period for Part B and starts three months before your 65th birthday or the 25th month of disability benefits from Social Security or the Railroad Retirement Board, includes the month of eligibility, and lasts for seven months.

You’ll also get a Special Election Period to enroll in a Special Needs Plan or switch plans in certain situations. These may include, but aren’t limited to:

• You have Medicare and develop a chronic condition.
• You move into a nursing home or other institution.
• You move out of your plan’s service area.
• Your Special Needs Plan leaves the Medicare program.

If you live in an institution, have Medicare and Medicaid, or have a chronic condition, you can enroll in a Special Needs Plan at any time.

The types of Medicare Special Needs Plans offered in your area will depend on your state and zip code. If you’d like help finding Special Needs Plans, you can contact eHealth to speak with a licensed insurance agent; we can check if there are Medicare plan options available in your area with coverage that may fit your specific health needs.