A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals. A special needs individual could be any one of the following:An institutionalized individual,
A dual eligible, or
An individual with a severe or disabling chronic condition, as specified by CMS.
A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan. There are three different types of SNPs:
Chronic Condition SNP (C-SNP).
Dual Eligible SNP (D-SNP).
Institutional SNP (I-SNP).
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SNPs are expected to follow existing MA program rules, including MA regulations at 42 CFR 422, as modified by guidance, with regard to Medicare-covered services and Prescription Drug Benefit program rules. All SNPs must provide Part D prescription drug coverage because special needs individuals must have access to prescription drugs to manage and control their special health care needs. SNPs should assume that, if no modification is contained in guidance, existing Part C and D rules apply.
Payment procedures for SNPs mirror the procedures that CMS uses to make payments to non-SNP MA plans. SNPs must prepare and submit bids like other MA plans, and are paid in the same manner as other MA plans based on the plan’s enrollment and risk adjustment payment methodology. All SNPs must abide by current CMS guidance on cost sharing requirements.
Eligibility for Special Needs Plans.
To enroll in a Medicare Special Needs Plan, you must meet the following eligibility requirements:.
• Be enrolled in Medicare Part A and Part B.
• Live in the service area of the Special Needs Plan.
• Meet the eligibility requirements that the Special Needs Plan targets (i.e., live in an institution; have Medicare and Medicaid; or have the chronic conditions( s) that the plan targets).
Medicare beneficiaries with end-stage renal disease are typically not allowed to enroll in a Medicare Advantage plan, with some exceptions. However, if there is a Special Needs Plan targeting end-stage renal disease beneficiaries in your service area, you may be eligible to enroll in this type of plan.
Like other Medicare Advantage plans, Special Needs Plans are available through private insurance companies that are approved by Medicare. All Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B. Some Medicare Advantage plans may also cover benefits beyond what Original Medicare covers, and your Medicare plan options and benefits can vary, depending on where you live.
Some Special Needs Plans include care-coordination services to help you better understand your condition and stick to your doctor’s treatment regimen. Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition.
Chronic-Condition Special Needs Plans may include provider networks with physicians and hospitals that specialize in treating the specific condition of its members, or they may have formularies that are tailored to include the prescription drugs that treat that illness. If you’re enrolled in a Special Needs Plan for dual eligibles, there may be certain social services available to help you coordinate your Medicare and Medicaid benefits.
It’s important to note that you still get all the coverage that is otherwise included with Original Medicare, Part A and Part B, and Medicare Part D. The Special Needs Plan simply offers extra coverage to help you better manage your particular situation, whether that’s living in a nursing home; coordinating your Medicare and Medicaid benefits; or treating a serious chronic illnes