Special Needs Plan: What It Is and Why You Might Want One

When it comes time for open enrollment each fall, you may hear about the Medicare Advantage Special Needs Plans (SNPs). These are a type of Medicare Advantage plan for people with additional heath needs, often due to a serious or chronic condition such as diabetes or dementia. They are also available to people who qualify for both Medicaid and Medicare.

The plans are fairly common: Almost 4 million people on Medicare were enrolled in one in 2021, according to the Kaiser Family Foundation.

SNPs are tailored for people with specific diseases or characteristics. This is important for anyone experiencing a chronic health issue, but especially for older adults, who are living longer and becoming a larger percentage of our population, according to the United States Census Bureau.

And the older you are, the more at risk you become for certain chronic conditions. But SNPs can also be tricky to figure out. Here’s what you need to know.

What is a Medicare Special Needs Plan?

A Medicare Special Needs plan is a type of Medicare Advantage Plan available only to people who have certain qualifying health conditions or situations.

There are different types of SNPs, and they offer specialized care and expanded coverage for specific health conditions and situations. For example, if you have heart disease or live in a nursing home—or if you qualify for both Medicare and Medicaid—an SNP can help meet your specific needs.

Who can join an SNP?

Anyone  who is eligible for Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), lives in the plan’s service area, and meets the plan’s eligibility requirements can join an SNP.

What are the different types of SNP plans and eligibility requirements?

There are several kinds of SNPs, and to be eligible to sign up, enrollees must meet the qualifications for at least one of these:

Chronic Condition SNP (C-SNP). About 9% of SNP enrollees are in these plans, which are for people with at least one of these chronic conditions:

• Alcohol or other drug dependence
• Autoimmune disorders, including rheumatoid arthritis and systemic lupus erythematosus (SLE) (not all autoimmune conditions qualify)
• Cancer (excluding pre-cancer conditions)
• Cardiovascular disorders, including coronary artery disease
• Chronic heart failure
• Dementia
• Diabetes
• End-stage liver disease
• End-stage renal disease (ESRD) requiring dialysis
• Severe blood disorders, including hemophilia and sickle-cell disease
• HIV/AIDS
• Chronic lung disorders, including asthma and emphysema
• Chronic and disabling mental health conditions, including bipolar disorders and major depressive disorders
• Neurologic disorders, including epilepsy, multiple sclerosis and Parkinson’s disease
• Stroke

Institutional SNP (I-SNP). You live in an institution (like a nursing home), or you require nursing care at home. About 2% of SNP enrollees are in these plans.

Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid. This is the most common SNP, with about 89% of enrollees in these plans. People with D-SNP can receive support in coordinating their Medicare plan with Medicaid, since it can be confusing to work through all the details. In addition, a D-SNP provides benefits that Medicare alone or Medicaid alone does not.

How does a Medicare SNP work?

Medicare SNPs must provide you with the same benefits as Original Medicare, but they usually offer more help and covered benefits than Original Medicare or other Medicare Advantage plans. This additional care includes:

A care coordinator. This person will help you stay healthy and follow your doctor’s orders. For example, a care coordinator for a person with diabetes on a C-SNP might help you monitor your blood sugar, eat right and exercise, and schedule preventive services such as eye and foot exams.

If you have a D-SNP, your care coordinator may help you access community resources and schedule transportation to doctor appointments.

Specialized care. Your SNP is designed to specifically serve people in your situation or with your condition. If you have a C-SNP, for example, for type 2 diabetes, your plan could include blood glucose and insulin management tools, vision, hearing, dental, and routine foot care—services that might not necessarily or normally be available with a non-SNP plan or Original Medicare. These are all features you may need to help you manage your disease.

Drug formularies tailored to your condition. The drug plans for SNPs are designed with a person’s treatment plan in mind. That means it most likely offers coverage for the most common medications prescribed to manage a person’s chronic condition. For example, someone with a heart condition such as congestive heart failure or asthma would typically have medications covered that are most used to treat that specific issue.

How much do SNP plans cost?

That depends. SNPs generally don’t cost more than other Medicare Advantage plans. But because some SNPs offer additional care, they may charge a monthly premium in addition to the base premium. This may mean paying a little more each month, but the tailored could possibly save your money and help safeguard your health. SNPs also set their own deductibles, copayments, and other cost-sharing for services. But if you’re on a D-SNP plan, there are no deductibles or copays if you stay in network.

In addition, SNPs cannot charge more than Original Medicare charges for certain kinds of care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care. But SNPs can charge higher copays for other services, including home health, durable medical equipment (DME), and inpatient hospital care. All SNPs are required to provide Part D coverage.

Can I get my healthcare from any doctor or network?

Usually, you need to stay in the Medicare SNP network, which is generally geared toward your specific needs or condition. There are two exceptions, however:

• Emergency or urgent medical care
• If you have end-stage renal disease and need out-of-area dialysis

You also generally need a referral to see a specialist, unless it’s for preventive services such as a mammogram or a Pap test and pelvic exam.

What questions should I ask before I enroll in an SNP?

Just as you would before joining any plan, your questions should be geared toward your individual needs. Here are some examples of things to ask to help you narrow down your choices.

• How do the SNP’s services compare with other plans available?
• What benefits does the SNP provide that will help with my special needs? For example, what special services will help me manage a chronic condition or improve my care in a nursing home?
• What costs should I expect for my coverage (premiums, deductibles, copayments)?
• Is there an annual limit on my out-of-pocket expenses?
• Will I be able to use my doctors? Are they in the plan’s network? If I join an Institutional SNP, will the plan’s network include my nursing home or home care provider?
• Am I ever allowed to go out of network?
• Do I need a referral to see a specialist?
• Are my drugs on the plan’s formulary?

Can I lose my SNP plan?

Yes, you can lose your SNP plan if you no longer meet its eligibility requirements (you lose Medicaid coverage, for example). The SNP will notify you that you’re no longer eligible for the plan, and you’re given at least another month to find another plan. Once you lose eligibility, you’ll have a three-month Special Enrollment Period to make another choice, either a new Medicare Advantage Plan or Original Medicare and a Part D plan.