Medicare Special Needs Plans

A Special Needs Plan (SNP) is a type of Medicare Advantage insurance plan aimed at meeting the unique care of people with certain diseases or characteristics. SNPs can play an important role in special needs planning for people with disabilities or chronic ailments.

What Is a Special Needs Plan?

A Special Needs Plan (SNP) is a type of Medicare Advantage coordinated care plan.

SNPs tailor the benefits, provider choices and drug formularies they offer to best serve the specific needs of beneficiaries.

For example, a private health insurance company might offer a SNP for people with heart disease. The plan benefits could include additional coverage for common medications used to treat heart disease as well as a network of doctors who specialize in cardiovascular health.

Like any Medicare Advantage plan, SNPs are required to provide the same basic benefits, rights and coverage as Original Medicare. But these plans may operate under different rules, network restrictions and costs.

All SNPs must provide Medicare prescription drug coverage. Some plans may offer additional benefits, such as vision, dental and hearing care.

Typically, you are required to seek care and services from providers within your SNP network. In most cases, SNPs require you to have a primary care doctor.

Different special needs plans are available depending on where you live. They are not available everywhere in the U.S.

A new Medicare beneficiary can join a SNP any time during the initial enrollment period.

Once enrolled, you can switch plans only between Oct. 15 and Dec. 7 each year, though a few exceptions to this rule exist.

Tip
You can use the Medicare Plan Finder to locate Special Needs Plans in your area.

Who Qualifies for Medicare Special Needs Plans?

Enrollment in a Medicare Special Needs Plan is limited to specific groups.

This can include people living in institutions, people who are dual eligible for Medicare and Medicaid, or people with certain chronic conditions.

To qualify for a Medicare Special Needs Plan, you must:
  • Be eligible for Medicare Parts A and B.
  • Be over 65 years old or have a disability and collect Social Security disability insurance.
  • Have a chronic condition, be eligible for Medicaid and Medicare, or need care at an institution, such as a nursing home.

You can only remain enrolled in a SNP if you meet the plan’s eligibility requirements.

Three Types of Special Needs Plans
Chronic Condition SNP (C-SNP)
For people with specific chronic conditions, such as cancer, dementia, diabetes, HIV, stroke and certain neurologic disorders.
Institutional SNP (I-SNP)
For people living in an institution, such as a nursing home, long-term care facility, assisted living facility or intermediate care facility for people with intellectual disabilities. To qualify, you must be in an institution for at least 90 days or expect to need institutional care for at least 90 days.
Dual Eligible SNP (D-SNP)
Low-income people over 65 and low-income people with severe disabilities can be eligible for Medicaid and Medicare at the same time. Dual eligible special needs plans serve beneficiaries who are dual enrolled in Medicare and Medicaid.

Chronic Condition SNPs

In 2020, there were 15 conditions that qualify for a Chronic Condition Special Needs Plan, or C-SNP.

Eligible conditions for a C-SNP include:
  • Autoimmune disorders
  • Cancer (excluding pre-cancer conditions)
  • Cardiovascular disorders
  • Chronic alcohol and other dependence
  • Chronic heart failure
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-Stage Renal Disease (ESRD) requiring dialysis
  • HIV/AIDS
  • Neurologic disorders
  • Severe hematologic disorders
  • Stroke

Costs of Special Needs Plans

If you have Medicaid, you will not pay Medicare deductibles and copays from providers in your Dual Eligible SNP network.

If you don’t have Medicaid, your exact costs will vary depending on the plan you select.

Special Needs Plans may include the following costs:
  • Medicare Part B premium
  • Monthly premium for your Special Needs Plan
  • Potential copayments, coinsurance or deductibles

FAQs

Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage.
Do I need a referral to see a specialist?
In most cases, you are required to get a referral to see a specialist.
What is a care coordinator in a SNP?
A care coordinator is a person who helps the beneficiary find appropriate services in his or her community. They help make sure people get the right care and information.
Last Modified: June 17, 2020

4 Cited Research Articles

  1. Office of the Assistant Secretary for Planning and Evaluation. (2019, April 8). Integrating Care Through Dual Eligible Special Needs Plans (D-SNPS): Opportunities and Challenges. Retrieved from https://aspe.hhs.gov/basic-report/integrating-care-through-dual-eligible-special-needs-plans-d-snps-opportunities-and-challenges#intro
  2. Centers for Medicare and Medicaid Services. (n.d.). What is a Special Needs Plan? Retrieved from https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans
  3. Medicare.gov. (n.d.). How Medicare Special Needs Plans (SNPs) Work. Retrieved from https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/how-medicare-special-needs-plans-snps-work
  4. Medicare.gov. (n.d.). Special Needs Plans. Retrieved from https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp