How Medicare SNPs work
Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Find out who can join a Medicare SNP.
Can I get my health care from any doctor, other health care provider, or hospital?
Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:
- Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
- If you have
End-Stage Renal Disease (ESRD)and need out-of-area dialysis
Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
Are prescription drugs covered?
All SNPs must provide Medicare prescription drug coverage.
Do I need to choose a primary care doctor?
In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.
Do I have to get a referral to see a specialist?
In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these:
- Yearly screening mammograms
- An in-network pap test and pelvic exam (covered at least every other year)
What else do I need to know about this type of plan?
A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) 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 (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.
- Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.
- If you have Medicare and
Medicaid [Glossary], your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.
- If you live in an institution, make sure that plan providers serve people where you live. Find out more about where SNPs are offered.