Medicare Plans for Special Needs: Explained

Medicare Plans for Special Needs are unique plans designed specifically for people with certain disabilities or health conditions. These plans can be very helpful in managing your healthcare costs and…

May 13, 2022

Written by Nikki Grillo

Medicare Plans for Special Needs are unique plans designed specifically for people with certain disabilities or health conditions. These plans can be very helpful in managing your healthcare costs and ensuring you have the coverage you need. 

This blog post will explain what Special Needs Plans are, how they work, and the different types of plans available. We will also discuss who is eligible for these plans and how to enroll.

What Are Special Needs Plans?

Medicare Special Needs Plans are a form of Medicare Advantage Plan, which are a substitute for Original Medicare. They’re available through private health insurance companies that have negotiated contracts with Medicare. All Medicare Advantage Plans must provide at least the same coverage as Original Medicare, Part A, and Part B. Some plans may also offer additional benefits, such as prescription drug coverage or dental and vision care. There are four kinds of Special Needs Plans:

Dual Special Needs Plans (D-SNPs):  These plans are for people who have both Medicare and Medicaid.

Chronic Special Needs Plans (C-SNPs): These plans are available for people that have one or more of the following severe or persistent chronic illnesses:

  • Chronic lung disorders
  • Autoimmune disorders
  • Cancer (excluding pre-cancer conditions) 
  • Cardiovascular disorders 
  • End-Stage Renal Disease (ESRD) requiring any mode of dialysis
  • Chronic heart failure 
  • Dementia 
  • Diabetes
  • End-stage liver disease 
  • Severe hematologic disorders
  • HIV/AIDS  
  • Chronic and disabling mental health conditions 

Institutional SNPs (I-SNPs): These plans are for people who live in a nursing home or long-term care facility.

Institutional-Equivalent Special Needs Plans (IE-SNPs):  These plans are for people who get care in an institution but don’t live there.

Special Needs Plans Eligibility

You’re eligible for a Special Needs Plan if you have Medicare and:

  • Are enrolled in Medicaid.
  • Have certain chronic conditions, such as diabetes or heart failure.
  • Live in a nursing home or long-term care facility.
  • Get care in an institution but don’t live there.

If you think you may be eligible for a Special Needs Plan, the first step is to contact your state Medicaid office. You can find their contact information on the Medicaid website. Once you have contacted your state Medicaid office, they will help you determine if you are eligible for a Special Needs Plan and assist you with enrolling. You can also get professional help from a private insurer. 

How to Enroll in a Special Needs Plan

If you think you might be eligible for a Special Needs Plan, the first step is to contact your state’s Medicaid office or the Social Security Administration. They can help you determine if you qualify for Medicaid or any other programs that can help pay your Medicare costs.

Once you know which programs you qualify for, you can start shopping for a Special Needs Plan that meets your needs and budget. You can enroll in a Special Needs Plan through the Medicare Plan Finder on Medicare.gov or by contacting the plan directly. This process can be made easier by contacting a private insurer that can help you out with all the details. 

What Do Special Needs Plans Cover?

Special Needs Plans must cover the same benefits as Original Medicare, Part A, and Part B. This includes hospital stays, doctor’s visits, and preventive care. Most plans also include prescription drug coverage. Some plans may offer additional benefits, such as dental or vision care. Each Special Needs Plan has different rules about what it covers and how much you pay out-of-pocket for each service.

When choosing a Special Needs Plan, it’s important to carefully compare the covered benefits and costs to make sure the plan is right for you. You can use the Medicare Plan Finder tool on Medicare.gov to see a list of available Special Needs Plans in your area and compare their features side-by-side.

Special Needs Plans Costs

You may be wondering how much Medicare SNPs cost. This question will vary depending on the insurer, your location, and the plan benefits. You can expect to pay a monthly premium for your SNP coverage. You may also have to pay copayments or coinsurance for some services.

Some Medicare SNPs are offered by private insurance companies that contract with Medicare. The Centers for Medicare & Medicaid Services (CMS) set rules about what benefits SNPs must cover. However, insurers can offer additional benefits beyond these minimum requirements.

Qualifying For Medicare and Medicaid

If you qualify for both Medicare and Medicaid, you may be able to get help paying your SNP premiums and other costs. For example, some states offer programs that help people with limited incomes pay for Medicare premiums and other out-of-pocket costs. 

SNPs Cost Without Other Assistance

If you enroll in a Medicare SNP and don’t have both Medicare and Medicaid (or other assistance from your state to pay for your Medicare premiums), the cost of your plan will vary based on which plan you choose. In general, you will be responsible for the following expenses:

  • Your monthly premium
  • The Medicare Part B deductible
  • Copayments or coinsurance for services covered by the plan

What Are Dual Special Needs Plans?

D-SNPs are for people who have both Medicare and Medicaid. D-SNPs coordinate your benefits between the two programs to ensure you get the coverage you need.

If you qualify for a D-SNP, you will be automatically enrolled in both Medicare and Medicaid. You will also be enrolled in a D-SNP that covers the services you need. D-SNPs offer the same benefits as Original Medicare, Part A, and Part B. They may also offer additional benefits, such as prescription drug coverage or dental and vision care.

Who Qualifies for a Dual Special Needs Plan?

You’re eligible for a D-SNP if you have Medicare and Medicaid. You must also be:

  • Enrolled in a state Medicaid program.
  • A U.S. citizen or legal resident.
  • Living in the plan’s service area.

To enroll in a D-SNP, you must first contact your state Medicaid office. They can help you determine if you are eligible for a D-SNP and assist you with enrolling.

How Do Dual Special Needs Plans Work?

D-SNPs coordinate your benefits between Medicare and Medicaid to ensure you get the coverage you need. In most cases, your Medicare costs will be covered by Medicaid, and there will be no premium for your D-SNP.

D-SNPs have networks of doctors, hospitals, and other providers that you can use for your care. You will likely pay less out-of-pocket if you use a provider in the plan’s network.

What Extra Benefits Does a Dual Special Needs Plan Provide?

In addition to the benefits that all Medicare Advantage plans must cover, DSNPs may offer extra benefits and services. For example, some DSNPs offer dental, vision, and hearing coverage. Other SNPs may offer transportation services or fitness programs.

DSNPs may also provide extra support for people with chronic conditions. For example, some plans offer disease management programs. These programs provide education and support to help people manage their health conditions.

How Much Do Dual Special Needs Plans Cost?

The cost of a DSNP will vary depending on the insurer, your location, and the plan benefits. You can expect to pay a monthly premium for your DSNP coverage. You may also have to pay copayments or coinsurance for some services.

If you qualify for both Medicare and Medicaid, you may be able to get help paying your DSNP premiums and other costs. For example, some states offer programs that help people with limited incomes pay for Medicare premiums and other out-of-pocket costs. 

What’s A SNPs Care Coordinator?

Most SNPs have care coordinators. A care coordinator is a health care professional who can help you get the services and support you need.

For example, if you have diabetes, your care coordinator can help you find a diabetic program. Or, if you’re having trouble taking your medications as prescribed, your care coordinator can connect you with resources to help. Care coordinators can also help you understand your insurance coverage and benefits. They can also answer any questions you have about your plan or health care in general.

How Do I Know If the Plan Covers a Service That I Need?

When you’re looking at Medicare SNPs, it’s important to make sure that the plan covers your services. You can find this information in the plan’s benefits booklet or other materials.

You can also call the customer service number for each plan and ask if a particular service is covered. Be sure to have the name of the service handy when you call. You may want to ask about coverage for:

  • Doctor Visits
  • Hospital Stays
  • Prescription Drugs
  • Dental Care
  • Vision Care
  • Mental Health Services
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

What Happens if I Need to Go to the Hospital or Doctor While I’m Traveling?

It’s important to know what will happen if you need medical care while traveling. If you have a Medicare SNP, likely, your plan will only cover you if you’re traveling within the United States. If you’re planning to travel outside of the country, you may want to purchase a separate travel insurance policy that will cover your medical expenses.

It’s important to know your plan’s rules before traveling. That way, you can avoid any surprises when it comes time to pay your medical bills.

Let Our Team Help You Choose A Plan

If you want to learn more about SNPs and how they might fit into your Medicare plan, Nesso Medicare can help you. Our expert agents will help you understand your coverage options and find a plan that meets all of your needs. 

At Nesso Group, we understand that choosing the right Medicare plan can be confusing; that’s why we’re here to help. We’re dedicated to helping our clients find the best possible coverage. 

Our team at Nesso Medicare can help you find the right Medicare plan for you, no matter your situation. Give us a call today to learn more about how we can help you navigate your coverage options and find a plan that meets all of your needs. We’re here to help you every step of the way!

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