Jane Dotson
Special Needs Plans (SNPs) are a unique type of Medicare Advantage plan offered by private insurance companies for certain qualified individuals. SNPs provide benefits and services to people with specific conditions, certain healthcare needs, or those who also have Medicaid. There are three types of SNPs: Dual Special Needs Plans (D-SNPs), Chronic Special Needs Plans (C-SNPs), and Institutional Special Needs Plans (I-SNPs). To be eligible for a C-SNP, you must have a severe or disabling chronic condition, such as cancer, cardiovascular disorders, or chronic lung disorders.
| Characteristics | Values |
|---|---|
| Plan types | HMO or PPO |
| Coverage | Medicare Part A and Part B benefits |
| Additional coverage | Extra services for special groups, e.g. extra hospital days for severe conditions |
| Eligibility | Must have Medicare Part A and Part B, live in the plan's service area, and meet eligibility requirements for one of the 3 types of SNPs |
| Types of SNPs | Dual Special Needs Plans (D-SNPs), Chronic Special Needs Plans (C-SNPs), Institutional Special Needs Plans (I-SNPs) |
| D-SNP eligibility | Have both Medicare and Medicaid ("dual eligible") |
| C-SNP eligibility | Severe or disabling chronic conditions, e.g. diabetes, cardiovascular disorders, cancer |
| I-SNP eligibility | Live in a skilled nursing facility or require a nursing home level of care for at least 90 days |
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What You'll Learn
Dual Special Needs Plans (D-SNPs) for dual Medicare and Medicaid eligibility
Special Needs Plans (SNPs) are a type of Medicare Advantage plan that offers broader Medicare coverage to a specific, limited population. SNPs are either HMO or PPO plan types, and they cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover. However, SNPs may also cover extra services tailored to the specific groups they serve. For example, if you have a severe condition like cancer or congestive heart failure and need a hospital stay, an SNP may cover extra days in the hospital.
Dual Special Needs Plans (D-SNPs) are a type of SNP for people who have both Medicare and Medicaid, known as "dual eligibles". D-SNPs combine all Medicare and Medicaid benefits into one easy-to-manage plan. D-SNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes.
D-SNPs are growing in popularity, with nearly 3 in 10 dual-eligible individuals enrolled in a D-SNP in 2021, a three-fold increase since 2011. This growth may be partly due to the automatic enrollment of some individuals into D-SNPs. In 2022, more than 9 in 10 dual-eligible individuals lived in counties where insurers offered at least one D-SNP.
D-SNPs may be attractive to dual-eligible individuals due to the availability of extra benefits, such as over-the-counter benefits, meals, and transportation services. These additional benefits may be covered by Medicaid as "Medicaid wrap-around services". However, it is unclear how well D-SNPs coordinate with Medicaid to provide the full range of benefits to dual-eligible enrollees.
It is important to note that states may determine eligibility differently for D-SNPs, so it is recommended to check with your state prior to enrolling.
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Chronic Special Needs Plans (C-SNPs) for severe chronic conditions
Chronic Special Needs Plans (C-SNPs) are a type of Medicare Advantage plan offered by private insurance companies for people with specific severe or disabling chronic conditions. C-SNPs cover the same health care services that all Medicare Advantage plans must, including Medicare Part A and Part B. However, they may also cover extra services tailored to the specific group they're designed to serve. For example, if you have a severe condition and need a hospital stay, a C-SNP may cover extra days in the hospital.
C-SNPs are only available to people who have certain qualifying conditions, which are defined in 42 CFR 422.2. There are 15 SNP-specific chronic conditions approved by the Centers for Medicare and Medicaid Services (CMS), including:
- Autoimmune disorders: polyarteritis nodosa, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, and systemic lupus erythematosus.
- Cancer (excluding pre-cancer conditions or in-situ status).
- Cardiovascular disorders: cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder.
- Chronic lung disorders: asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension.
- Chronic and disabling mental health conditions: bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder.
- Severe hematologic disorders: aplastic anemia, hemophilia, immune thrombocytopenic purpura, myelodysplastic syndrome, and sickle-cell disease (excluding sickle-cell trait).
CMS has also identified five combinations of commonly co-existing chronic conditions that may be the focus of a C-SNP:
- Diabetes mellitus and chronic heart failure.
- Chronic heart failure and cardiovascular disorders.
- Diabetes mellitus and cardiovascular disorders.
- Diabetes mellitus, chronic heart failure, and cardiovascular disorders.
To enrol in a C-SNP, an individual needs to have only one of the qualifying conditions. It is important to note that C-SNPs are not available everywhere in the US, and the availability of plans will depend on where you live. Therefore, it is recommended to check directly with a plan provider to see if they offer a C-SNP that meets your healthcare needs.
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Institutional Special Needs Plans (I-SNPs) for nursing home residents
Special Needs Plans (SNPs) are a type of Medicare Advantage plan that combines the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). SNPs are designed for individuals with specific severe or chronic diseases, certain healthcare needs, or those who are eligible for both Medicare and Medicaid. They cover the same healthcare services as all Medicare Advantage plans but may also offer additional services tailored to the specific group they serve. SNPs are either HMO or PPO plan types.
Institutional Special Needs Plans (I-SNPs) are a type of SNP that caters to individuals who reside in a care facility, such as a nursing home, or receive nursing care at home. Specifically, I-SNPs are intended for those who have had or are expected to require, for 90 days or longer, the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.
To qualify for an I-SNP, an independent and impartial entity must administer a state assessment tool to determine the institutional level of care (LOC) needs. This assessment must be conducted by an entity that the I-SNP does not own or control and must utilize the same methodology and tools as those employed for individuals living in the community.
It is important to note that the availability of SNPs may vary annually and by location. Therefore, it is advisable to review the plans offered in your area to understand the specific benefits and services provided by each SNP.
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SNP eligibility requirements
Special Needs Plans (SNPs) are a unique kind of Medicare Advantage plan offered by private insurance companies for certain qualified individuals. SNPs cover the same Medicare Part A and Part B benefits that all Medicare Advantage Plans cover. However, they might also cover extra services for the special groups they serve. To be eligible for an SNP, you must meet the following requirements:
Dual Special Needs Plans (D-SNPs)
D-SNPs are for people with both Medicare and Medicaid (called "dual-eligible"). To be eligible for a D-SNP, you must be enrolled in or eligible for both Medicare and full Medicaid benefits. D-SNPs can help coordinate your benefits between Medicare and Medicaid.
Chronic Special Needs Plans (C-SNPs)
C-SNPs are for people living with severe or disabling chronic conditions. To be eligible for a C-SNP, you must have received a medical diagnosis for one or more of the following health conditions:
- Autoimmune disorders: polyarteritis nodosa, polymyalgia rheumatica, polymyositis, rheumatoid arthritis, and systemic lupus erythematosus
- Cancer (excluding pre-cancer conditions or in-situ status)
- Cardiovascular disorders: cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder
- Severe hematologic disorders: aplastic anemia, hemophilia, immune thrombocytopenic purpura, myelodysplastic syndrome, and sickle-cell disease (excluding sickle-cell trait)
- Chronic lung disorders: asthma, chronic bronchitis, emphysema, pulmonary fibrosis, and pulmonary hypertension
- Chronic and disabling mental health conditions: bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder
- Diabetes mellitus
- Chronic heart failure
Institutional Special Needs Plans (I-SNPs)
I-SNPs are for people who live in a skilled nursing facility or require a level of care usually provided in a nursing home. To be eligible for an I-SNP, you must meet your state's guidelines for requiring nursing home-level care for at least 90 days, whether you live in an institution or a community setting. You can still qualify for an I-SNP before receiving care for at least 90 days if it is likely that you will need long-term care for at least 90 days.
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SNP enrollment
Special Needs Plans (SNPs) are a type of Medicare Advantage plan that combines the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). SNPs are designed for people with specific conditions, certain healthcare needs, or who also have Medicaid. SNPs are either HMO or PPO plan types, and they might cover extra services for the special groups they serve.
There are three types of SNPs:
- Dual Special Needs Plans (D-SNPs): These are for people who have both Medicare and Medicaid, often referred to as "dual eligibles." D-SNPs combine Medicare Part A and Part B benefits with Medicare Part D prescription drug coverage, and provide extra benefits not included in either Medicare or Medicaid. To enrol in a D-SNP, you must verify that you have Medicaid by showing your Medicaid card or a letter from Medicaid. Some D-SNPs only serve beneficiaries with full Medicaid benefits.
- Chronic Special Needs Plans (C-SNPs): These plans are for people living with severe, disabling, or chronic conditions such as cardiovascular disorders, chronic heart failure, chronic lung disorders, or diabetes. To enrol in a C-SNP, you must get a note from your doctor confirming that you have the condition addressed by the SNP.
- Institutional Special Needs Plans (I-SNPs): I-SNPs are for people who live in a skilled nursing facility or a contracted assisted living facility and need a similar level of care. To enrol in an I-SNP, you must meet your state's guidelines for requiring a nursing home level of care for at least 90 days, whether in an institution or community setting. You can still qualify for an I-SNP before receiving care for 90 days if it is likely that you will need long-term care for that duration.
To enrol in a SNP, you must apply and prove that you meet the eligibility criteria. You can enrol by calling Medicare (1-800-633-4227) or the plan directly. You can only remain enrolled in an SNP if you continue to meet the special conditions of the plan.
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Frequently asked questions
There are three types of SNPs: Dual Special Needs Plans (D-SNPs), Chronic Special Needs Plans (C-SNPs), and Institutional Special Needs Plans (I-SNPs). D-SNPs are for people with both Medicare and Medicaid, C-SNPs are for people with severe or disabling chronic conditions, such as cardiovascular disorders, chronic heart failure, diabetes, or cancer, and I-SNPs are for people who live in a skilled nursing facility or require a similar level of care.
To qualify for a C-SNP, you must have received a medical diagnosis for one or more of the eligible chronic conditions, such as cardiovascular disorders, chronic heart failure, diabetes, or cancer. You can enrol at any time as long as you have the condition and meet the eligibility requirements.
A D-SNP combines your Medicare Part A and Part B benefits with your Medicare Part D prescription drug coverage. It also provides extra benefits not provided by either Medicare or Medicaid and helps coordinate your Medicare and Medicaid plans.
