What is a Medicare Special Needs Plan?

Medicare Special Needs plans are a special category within Medicare Advantage plans, the programs offered by private insurers and that bundle whatever the Original Medicare Plans A, B and usually D offer, plus some more benefits. Medicare Special Needs are, as the name suggests, developed to meet the needs of beneficiaries in special demographics, such as people suffering from certain diseases or who have certain characteristics. Here are some important things to know about Medicare Special Needs plans.

Medicare Colorado

The Categories of People Who Can Become Beneficiaries for Medicare Special Needs Plans

According to Medicare Colorado specialists, Medicare Special Needs plans are currently available for the following categories of individuals:

  • Institutionalized beneficiaries – one category of people who can enroll into Special Needs plans are people who live in certain types of institutions, such as nursing facilities or who live in their home, but need special, professional care on a regular basis;
  • People eligible for Medicare as well as for Medicaid – also called dually eligible beneficiaries, the individuals belonging to this category usually have low incomes and they also meet the eligibility criteria for Medicare Part A and/or Part B;
  • Beneficiaries who suffer from certain chronic conditions – this group includes individuals who suffer from one or multiple chronic conditions. The list of the illnesses and conditions that provide eligibility is very long and includes some of the most common chronic illnesses, such as cardiovascular disease, diabetes, congestive heart failure, dependence from alcohol or from other substances, severe hematologic disorders, dementia, stroke, neurological disorders, diabetes, severe lung and liver diseases, mental disorders, osteoarthritis and HIV/AIDS.

How Medicare Special Needs Plans Work

To be able to enroll into a Special Needs plan, the potential beneficiaries need to belong to one of the eligibility groups and they also need to fulfill the following conditions:

  • They need to have a Part A and a Part B insurance – Part A is the component of the Medicare insurance that covers for hospital stays, while Part B is the coverage for outpatient care, such as the professional administration of certain medications;
  • They need to live in the service area of the plan selected;
  • They need to be able to prove that they suffer from one of the chronic conditions on the Special Needs list or that they belong to the other two eligibility groups specified above.

The individuals who are eligible for SNP enrollment will need to choose their plan based on the condition they suffer from and based on their other characteristics. To be able to maintain their enrollment, SNP beneficiaries need to continue to meet the conditions stipulated for joining the SNP – for example, if a dually eligible beneficiary loses their Medicaid eligibility, the beneficiary will be required to dis-enroll from the SNP for the period when one or more of the conditions are not fulfilled.

For some of the enrollees, Medicare Special plans are available for free, such as in the case of dually eligible beneficiaries, while for some other people, the process involves premiums the amount of which is determined based on many factors and complex calculations that take into consideration individual features.