If you have a chronic condition, you may be able to get a special Medicare plan called a special needs plan (SNP). It's a type of Medicare Advantage Plan that is limited to people with certain diseases or conditions. A Medicare SNP provides coverage for hospital stays, office visits, prescription drugs, and all other Medicare-covered services.
To join a Medicare SNP, you must have Medicare Part A and Part B. You also must live in the plan's service area. Then, you may be eligible if at least one of these is true for you:
- You have one or more severe or disabling chronic conditions.
- You live in a nursing home or need nursing care at home.
- You have Medicare and Medicaid.
Benefits of a Medicare SNP
A Medicare SNP combines hospital, medical, and prescription drug benefits. That makes it easier to coordinate all the parts of your care, makes it easier to follow your doctor’s advice for diet and prescriptions, and can help you get help from the community. All of your medical services are provided through a single plan.
Once you are enrolled in a plan, before you receive a service, it is important to make sure the SNP plan covers the services you need. If you are not sure, you can ask the plan for a decision in advance to make sure the service is covered.
A Medicare SNP is designed just for you. An SNP tailors your benefits, doctors, and drug coverage to meet your specific needs. If you have congestive heart failure, your SNP might offer special programs to manage care for people with congestive heart failure. It also might help you find doctors who specialize in treating it.
You also may have a care coordinator. This person makes sure you get the preventive care and treatments you need to stay as healthy as possible. Your care coordinator can connect you with helpful community services.
If you have Medicare and Medicaid, a Medicare SNP can help coordinate them.
You won't need extra drug coverage. Medicare SNPs include drug coverage. That means you do not need Part D, Medicare's prescription drug plan.
You may not need other insurance. You may have had Medicare supplemental insurance called Medigap. Medigap does not work with Medicare SNPs, so it will not cover your premiums, deductibles, or co-payments. Medicare SNPs often cover additional services that may duplicate Medigap, like extra days in the hospital. It is important to review the benefits of both plans to make sure you are not paying for supplemental insurance you do not need.
Chronic Conditions SNPs Apply To
If you have cancer or heart disease, you could get a SNP. Those are among the 15 chronic conditions that SNPs cover. Other examples are autoimmune disorders, diabetes, dementia, lung disease, and end-stage liver and kidney diseases. A SNP may focus on one chronic condition or several.
For a full list of conditions, go to Medicare.gov and search “special needs plan."
What a Medicare SNP Costs
Your out-of-pocket costs will depend on how often you need care and the type of care you need. Whether you use doctors who are in your SNP's network or out of the network also will make a difference. You should know that:
- If you can get both Medicare and Medicaid, or if you have a limited income, you'll be able to get care without spending as much money.
- Your costs will vary depending on the SNP you choose, but they will be the basic costs of a Medicare Advantage plan.
Before you join a SNP, ask what you will be expected to pay.
How to Sign Up for a Medicare SNP
First, find a SNP in your area.
- Call 800-MEDICARE (800-633-4227).
- Go online to the Medicare Plan Finder website: www.medicare.gov/find-a-plan.
- Contact your local State Health Insurance Assistance Program. (Scroll to SHIP under "choose organization.") People there can help you sign up for a Medicare SNP.
Then, fill out an application form. You can ask the SNP to send you a form. Some SNPs will let you sign up through their website. Or if you have Medicare and Medicaid, you may be able to sign up at Medicare.gov. For more help, call 800-MEDICARE.
When to Enroll in an SNP
If you are joining Medicare for the first time: You can sign up during your first Medicare enrollment period. That is usually the month you turn 65 and the 3 months before and after that month.
If you already have Medicare: You can join during the next open enrollment period.
If you develop a severe disability and enter a nursing home: You can join at any time.
What Else You Should Know
Your SNP will have a network of providers. You may have to pick a primary care doctor and may need a referral to see a specialist. And most of the time you will have to use doctors, hospitals, and other providers in the network. Emergencies are an exception.
If you aren't happy with your SNP plan, you may switch to original Medicare at any time. During the annual open enrollment, you can choose another Medicare Advantage or SNP plan.
If you move out of the area that your SNP serves, you can switch plans or go back to original Medicare.
If you are no longer eligible for SNP coverage, you can join another Medicare plan or go back to original Medicare.