How Medicare Special Needs Plans (SNPs) work

Can I join a Medicare SNP?

You can join a Medicare SNP if you meet these requirements:

  • You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) .
  • You live in the plan's service area .
  • You meet the plan's eligibility requirements for one of the 3 SNP types:

1. Chronic Condition SNP (C-SNP)  You have one or more of these severe or disabling chronic conditions:

  • Chronic alcohol and other dependence
  • Certain autoimmune disorders
  • Cancer (excluding pre-cancer conditions)
  • Certain cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-Stage Renal Disease (Esrd) requiring dialysis (any mode of dialysis)
  • Certain severe hematologic disorders
  • HIV/AIDS
  • Certain chronic lung disorders
  • Certain chronic and disabling mental health conditions
  • Certain neurologic disorders
  • Stroke

2. Institutional SNP (I-SNP) – You live in the community but need the level of care a facility offers, or if you live (or are expected to live) for at least 90 days straight in a facility like a:

  • Nursing home
  • Intermediate care facility
  • Skilled nursing facility
  • Rehabilitation hospital
  • Long-term care hospital
  • Swing-bed hospital
  • Psychiatric hospital
  • Other facility that offers similar long-term, health care services and whose residents have similar needs and health care status as residents of the facilities listed above

3. Dual Eligible SNP (D-SNP) – You’re eligible for both Medicare and Medicaid. D-SNPs contract with your state Medicaid program to help coordinate your Medicare and Medicaid benefits.

Each Medicare SNP limits its membership to people in one of these groups, or a subset of one of these groups.

For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure. The plan might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan's drug 

formulary

 would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition, and have all their care coordinated through the Medicare SNP.

Where are Medicare SNPs offered?

Each year, different types of Medicare SNPs may be available in different parts of the country. Insurance companies decide where they’ll do business, so Medicare SNPs may not be available in all parts of the country.

Insurance companies can decide that a plan will be available to everyone with Medicare in a state, or only in certain counties. Insurance companies may also offer more than one plan in an area, with different benefits and costs. Each year, insurance companies offering Medicare SNPs can decide to join or leave Medicare.

Find and compare Medicare SNPs in your area.

What do I pay in a Medicare SNP?

If you have Medicare and Medicaid, most of the costs of joining a Medicare SNP will be covered for you. Contact your Medicaid office for more information and to see if you qualify for Medicaid benefits.

If you don't have both Medicare and Medicaid (or get other help from your state paying your Medicare premiums), your exact costs will vary depending on the plan you choose. In general, you'll pay the basic costs of having a Medicare Advantage plan

What benefits and services are covered in Medicare SNPs?

Medicare SNPs cover the same Medicare services that all Medicare Advantage plans must cover. Medicare SNPs may also cover extra services tailored to the special groups they serve, like extra days in the hospital. Contact your plan to learn exactly what benefits and services the plan covers.

What is a care coordinator in a Medicare SNP?

Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. A care coordinator is someone who helps make sure people get the right care and information.

For example, a Medicare SNP for people with diabetes might use a care coordinator to help members do these things:

  • Monitor their blood sugar
  • Follow their diet
  • Get proper exercise
  • Schedule preventive services (like eye and foot exams)
  • Get the right prescriptions to prevent complications

A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members access community resources and coordinate their different Medicare and Medicaid services

When can I leave a Medicare SNP?

You can stay enrolled in a Medicare SNP only if you continue to meet the special conditions served by the plan.

Example:

Mr. Johnson joined a Medicare SNP that only serves members with both Medicare and Medicaid. Mr. Johnson loses his Medicaid eligibility. Medicare requires Mr. Johnson's plan to disenroll him unless he becomes eligible for Medicaid again within the plan's grace period.

The grace period is at least one month long, but plans can choose to have a longer grace period. If you lose eligibility for the plan, you'll have a Special Enrollment Period to make another choice.

This Special Enrollment Period starts when your Medicare SNP notifies you that you're no longer eligible for the plan. It continues during the plan's grace period, and if you're disenrolled from the plan at the end of the grace period, it continues for 2 months after your coverage ends. It's very important to review your coverage options at this time to make sure you continue to have the Medicare health and prescription drug coverage you want.