what are the three types of special needs plans
Special Needs Plans (SNPs) are a type of Medicare Advantage Plan specifically designed to provide targeted care and limit enrollment to special needs individuals. These individuals may include those who are institutionalized, dual eligible (those who have both Medicare and Medicaid), or those with severe or disabling chronic conditions as specified by the Centers for Medicare & Medicaid Services (CMS).
SNPs are a form of Medicare Advantage (MA) coordinated care plan (CCP) and can be structured as a local or regional preferred provider organization (LPPO or RPPO), a health maintenance organization (HMO), or an HMO Point-of-Service (HMO-POS) plan. The goal of SNPs is to provide services that are specifically tailored to the unique healthcare needs of their enrollees.
The statutory and regulatory history of SNPs dates back to the Medicare Modernization Act of 2003, which established the SNP program with the authority to operate initially until December 31, 2008. This authority has since been extended, although there was a moratorium on approving new SNPs after January 1, 2008.
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SNPs include care coordination services and tailor their benefits, provider choices, and drug lists (formularies) to meet best the specific needs of the groups they serve. They cover the same Medicare Part A and Part B benefits as all Medicare Advantage Plans. Still, they may also offer additional services for the special groups they serve, such as extra days in the hospital for those with severe conditions.
To join an SNP, individuals must live in the plan’s service area and meet the eligibility requirements for one of the three types of SNPs: Dual Eligible SNP (D-SNP), Chronic Condition SNP (C-SNP), or Institutional SNP (I-SNP). SNPs are offered in various parts of the country, and their availability can change each year as insurance companies decide where they will do business.
The Three Types of Special Needs Plans Are:
Dual Eligible Special Needs Plans (D-SNPs)
Dual Eligible Special Needs Plans (D-SNPs) are designed for individuals entitled to Medicare and Medicaid. These plans coordinate the delivery of both Medicare and Medicaid benefits, including care management, disease management, and other clinical services. D-SNPs can also offer supplemental benefits not typically available under Medicare but offered under Medicaid. Eligibility for D-SNPs includes categories such as Full Medicaid, Qualified Medicare Beneficiary without other Medicaid (QMB Only), QMB Plus, and others. The specific eligibility categories may vary by state.
Chronic Condition Special Needs Plans (C-SNPs)
Chronic Condition Special Needs Plans (C-SNPs) are designed for individuals with specific severe or disabling chronic conditions. These conditions can include diabetes, lung disorders, cardiovascular disorders, chronic heart failure, or end-stage renal disease. C-SNPs aim to improve health outcomes with a customized approach to care, including tailored benefits, individualized care plans, and a dedicated care team. All C-SNPs are required to provide prescription drug coverage, and most include coverage for routine vision and hearing care. Eligibility for a C-SNP depends on the individual having one or more of the specified chronic conditions.
Institutional Special Needs Plans (I-SNPs)
Institutional Special Needs Plans (I-SNPs) are designed for individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility. I-SNPs cover inpatient and outpatient services, including medically necessary treatments and preventive services. To be eligible for an I-SNP, an individual must need the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more.
Eligibility and Enrollment Process for Special Needs Plans (SNPs)
Dual Eligible Special Needs Plans (D-SNPs)
To be eligible for a D-SNP, individuals must be entitled to both Medicare and Medicaid. These plans are designed to coordinate the delivery of Medicare and Medicaid benefits, including care management and other clinical services. The specific eligibility categories for D-SNPs may vary by state, including Full Medicaid, Qualified Medicare Beneficiary without other Medicaid (QMB Only), and QMB Plus, among others.
Chronic Condition Special Needs Plans (C-SNPs)
Eligibility for C-SNPs requires individuals to have one or more specific severe or disabling chronic conditions. A note from a doctor confirming the chronic condition addressed by the SNP is necessary to enroll. If the C-SNP cannot verify the individual’s eligibility by the first month enrolled, the individual will be disenrolled at the end of the next month. However, they will have a Special Enrollment Period to enroll in a new plan.
Institutional Special Needs Plans (I-SNPs)
I-SNPs are for individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care facility, such as a skilled nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility. Eligibility for I-SNPs requires either living in a long-term care facility served by the SNP for at least 90 days or meeting the state’s guidelines for requiring a nursing home level of care for at least 90 days, whether in an institution or a community setting.
Enrollment Process
To enroll in an SNP, individuals must apply and prove that they meet the SNP’s eligibility criteria. The SNP may require periodic proof to ensure continued eligibility. Enrollment can be done by calling Medicare or the plan directly. Specific enrollment periods, such as the Annual Enrollment Period from October 15 through December 7 or Special Enrollment Periods, may occur due to qualifying life events. It is important to enroll during these periods to avoid potential issues with coverage.
Special Needs Plans (SNPs) Coverage Details
Special Needs Plans (SNPs) are a type of Medicare Advantage Plan designed to serve individuals with specific diseases, certain healthcare needs, or who also have Medicaid. SNPs include care coordination services and tailor their benefits, provider choices, and list of covered drugs (formularies) to meet best the specific needs of the groups they serve.
Care Coordination Services
SNPs provide care coordination services to ensure beneficiaries receive the proper care at the right time. This includes coordinating health services and integrating care to cover the full range of a beneficiary’s needs. The Model of Care (MOC) provides the foundation for promoting SNP quality, care management, and care coordination processes.
Provider Choices
SNPs offer a network of providers tailored to meet the specific needs of their groups. These networks vary in size and the populations they serve, and they may cover a specified area, such as a state or a county. The providers in these networks are experienced in treating the specific conditions or needs of the SNP beneficiaries.
Covered Drugs (Formularies)
SNPs have a list of covered drugs, also known as a formulary, which is selected in consultation with a team of health care providers. The drugs chosen represent the prescription therapies believed to be a necessary part of a quality treatment program. The formulary is continuously under review, and as changes occur, the version on the website is updated.
Additional Benefits
SNPs may also cover extra services for the special groups they serve. For example, if a beneficiary has a severe condition, like cancer or congestive heart failure, and needs a hospital stay, an SNP may cover extra days in the hospital. Some SNPs may also provide special programs for certain conditions, such as programs that help people with congestive heart failure.
Costs and Premiums for Special Needs Plans (SNPs)
Special Needs Plans (SNPs) are Medicare Advantage Plans that cater to individuals with specific needs, such as certain diseases, health care needs, or dual eligibility for Medicare and Medicaid. The costs associated with SNPs can vary based on the plan and the individual’s circumstances.
Monthly Premiums
SNPs may charge a monthly premium in addition to the standard Medicare Part B premium. However, the amount of the premium varies by plan. Some SNPs may have $0 premiums, while others may charge more.
Coverage for Dual Eligibles
Most of the costs associated with SNPs are typically covered for dual-eligible individuals (entitled to both Medicare and Medicaid). Depending on the state and the individual’s eligibility, Medicaid may cover some Medicare costs. This can include coverage for Medicare premiums, deductibles, and copays.
Cost-Sharing
SNPs cannot charge more than what Original Medicare charges for certain types of care, such as chemotherapy, dialysis, and skilled nursing facility care. However, they may set their own deductibles, copayments, and other cost-sharing for services. For other services, SNPs can charge higher copays, including for home health, durable medical equipment (DME), and inpatient hospital care.
Additional Benefits
SNPs are required to provide Medicare Part D drug coverage. They may also offer additional benefits, such as vision, hearing, or dental care, which can affect the plan’s overall cost.
State-Specific Costs
State-specific rules and programs can also influence the costs associated with SNPs. For example, some states may have programs that help cover the Medicare Part B premium for eligible individuals.
what are the 3 types of special needs plans
| Dual Eligible Special Needs Plans (D-SNPs) | Chronic Condition Special Needs Plans (C-SNPs) | Institutional Special Needs Plans (I-SNPs) | |
|---|---|---|---|
| Who They Serve | Individuals who are entitled to both Medicare and Medicaid | Individuals with specific severe or disabling chronic conditions | Individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care facility |
| Benefits | Coordinate the delivery of Medicare and Medicaid benefits, including care management and other clinical services | Aim to improve health outcomes with a customized approach to care, including tailored benefits, individualized care plans, and a dedicated care team | Cover inpatient and outpatient services, including medically necessary treatments and preventive services |
| Eligibility | Full Medicaid, Qualified Medicare Beneficiary without other Medicaid (QMB Only), QMB Plus, among others | One or more of the specified chronic conditions | Need the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more |
Comparison with Other Medicare Advantage Plans
Special Needs Plans (SNPs) are a subset of Medicare Advantage Plans designed to provide targeted care for individuals with specific needs. Here’s how they compare to other Medicare Advantage plans:
Targeted Beneficiary Population
SNPs are unique in that they limit enrollment to special needs individuals, such as those who are institutionalized, dual eligible (those who have both Medicare and Medicaid), or those with severe or disabling chronic conditions. Other Medicare Advantage plans are generally available to all Medicare beneficiaries.
Care Coordination Services
SNPs include care coordination services to manage beneficiaries’ health services and integrate care to cover a beneficiary’s needs. While some other Medicare Advantage plans may offer care coordination, SNPs must have a Model of Care (MOC) specifically tailored to the special needs population they serve.
Provider Networks
SNPs tailor their provider networks to meet the specific needs of their enrollees, often including providers experienced in treating the specific conditions of the SNP beneficiaries. Other Medicare Advantage plans may not have such specialized networks.
Benefits and Services
SNPs may offer additional benefits and services not typically covered by other Medicare Advantage plans, such as extra days in the hospital for those with severe conditions. They also must provide Medicare Part D drug coverage. Other Medicare Advantage plans may offer a different set of supplemental benefits.
Cost-Sharing and Rebates
SNPs often use rebates to supplement Medicaid’s “wrap around” benefits, such as covering dental and vision care, which may not be as prevalent in other Medicare Advantage plans. They also cannot charge more than what Original Medicare charges for certain types of care.
Access to Supplemental Benefits
Enrollees in SNPs have greater access to certain supplemental benefits such as transportation, meal benefits, bathroom safety devices, and in-home support services compared to other Medicare Advantage enrollees.
Satisfaction and Performance
While SNPs are expected to provide robust care management tailored to dual eligibles, studies have shown that D-SNPs did not perform better than other Medicare Advantage plans in areas pertinent to care, such as communication with patients about health problems, treatments, and medications. This indicates that the specialized nature of SNPs does not necessarily translate into higher satisfaction or better performance in all care areas.
Changes in Eligibility Status for Special Needs Plans (SNPs)
When an individual enrolled in a Special Needs Plan (SNP) no longer meets the eligibility requirements for that plan, specific procedures and protections are in place to address the change in their situation.
Institutional Special Needs Plans (I-SNPs)
For I-SNPs, if an enrollee changes residence, the plan must document that it is prepared to implement a CMS-approved Model of Care (MOC) at the enrollee’s new location or in another I-SNP contracted long-term care setting that provides an institutional level of care. This ensures continuity of care for the enrollee even if their living situation changes.
General SNP Eligibility Changes
If an individual in any SNP (D-SNP, C-SNP, or I-SNP) loses eligibility—for example, if they lose Medicaid coverage—the SNP may continue to provide coverage for a period of time if it seems likely that the individual will regain eligibility. Depending on the plan, this period can range from 30 days to six months. If the individual does not regain eligibility within this time, they will be disenrolled from the SNP.
Notification and Special Enrollment Period
The SNP must send a written notice within 10 days of learning that an enrollee no longer meets the eligibility requirements. This notice explains that the individual will be disenrolled if they do not regain eligibility within a certain timeframe. If the individual remains ineligible, the SNP must send a second notice informing them that their coverage will be terminated. At this point, the individual will have a Special Enrollment Period (SEP) to enroll in a new Medicare Advantage Plan or return to Original Medicare. To enroll in a new plan, the individual can call 1-800-MEDICARE (633-4227).
Continuity of Coverage
It’s important to note that when an individual is trying to regain eligibility or is in the process of enrolling in a new plan, they continue to have coverage. This ensures no gap in their access to necessary healthcare services.
Role of Primary Care Doctor in SNPs
The primary care doctor plays a crucial role in managing all care within the Special Needs Plans (SNPs) network. As the leading health care provider, the primary care doctor acts as a care coordinator, managing all the patient’s care within the SNP network in their service area.
SNPs are designed to provide extra benefits and team-based care to improve outcomes and decrease costs for special needs populations through improved coordination. The primary care doctor is central to this coordination, ensuring the patient receives the proper care at the right time. This includes coordinating health services and integrating care to cover the full range of a patient’s needs.
The primary care doctor is also responsible for creating an Individualized Care Plan (ICP) for the patient, which outlines the patient’s health goals and the services and treatments needed to achieve these goals. This plan is developed in collaboration with an Interdisciplinary Care Team (ICT), which may include specialists, nurses, social workers, and other healthcare professionals.
In addition to coordinating care, the primary care doctor also plays a key role in improving access to medical, mental health, and social services, as well as affordable care and preventive health services. They can help patients navigate the healthcare system, understand their health conditions, and make informed decisions about their care.
The top companies offering Medicare Advantage Plans that include Special Needs Plans (SNPs):
The top companies offering Medicare Advantage Plans that include Special Needs Plans (SNPs):
**Humana**: Humana is highlighted for offering Medicare Advantage Special Needs Plans (SNPs) that provide specialized healthcare tailored to specific conditions or eligibility, such as for those with both Medicare and Medicaid.
**UnitedHealthcare**: UnitedHealthcare offers Medicare Advantage plans with an extensive medical network and includes SNPs among their offerings. They are noted for having the largest Medicare Advantage medical and dental networks.
**Anthem**: Anthem provides Medicare Advantage SNPs for people with disabilities, certain chronic conditions, or limited incomes. Depending on eligibility, they often have $0 premiums, deductibles, and copays.
**Aetna**: Aetna offers Medicare Advantage DSNP (dual-eligible Special Needs Plan) for individuals with both Medicare and Medicaid, with benefits that work alongside Medicaid benefits.
These companies are among the insurers that provide SNPs designed to serve high-need populations and may offer additional benefits such as care coordination services, transportation for medical needs, and in-home support services. When considering a SNP, it’s important to review the specific benefits and costs associated with each plan and company, as these can vary.
Frequently Asked Questions
What are the 3 types of Medicare special needs plans?
The three types of Medicare Special Needs Plans (SNPs) are Dual Eligible Special Needs Plans (D-SNPs), Chronic Condition Special Needs Plans (C-SNPs), and Institutional Special Needs Plans (I-SNPs).
What is a special needs plan?
A Special Needs Plan (SNP) is a type of Medicare Advantage plan that provides benefits and services to people with specific diseases, certain healthcare needs, or who also have Medicaid. SNPs include care coordination services and tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of their groups.
How do you qualify for a SNP plan?
To qualify for a SNP, you must meet the eligibility requirements for one of the three types of SNPs. For D-SNPs, you must be entitled to both Medicare and Medicaid. For C-SNPs, you must have a specific severe or disabling chronic condition. For I-SNPs, you must have had or are expected to need the level of services provided in a long-term care facility for 90 days or longer.
Which consumer may be a good candidate for a D-SNP?
A good candidate for a D-SNP is an individual who meets the eligibility requirements for both Medicare and Medicaid. This could include those over 65 who are not on Medicaid but receive Extra Help or assistance from their state, or those under 65 who meet the requirements for low-income families, pregnant women and children, individuals receiving Supplemental Security Income (SSI), disability, or other special situations.
Do Medicare special needs plans cover drugs?
Yes, all Medicare Special Needs Plans must provide Medicare prescription drug coverage.
What are the benefits of a Medicare special needs plan?
Medicare Special Needs Plans offer benefits tailored to the needs of the individuals they serve. These may include care coordination services, tailored benefits, individualized care plans, and a dedicated care team. They also cover the same Medicare Part A and Part B benefits as all Medicare Advantage Plans. Some SNPs might also cover extra services for the special groups they serve, such as extra days in the hospital for those with severe conditions.
What is a chronic special needs plan?
A Chronic Condition Special Needs Plan (C-SNP) is a type of Medicare Special Needs Plan that serves individuals with specific severe or disabling chronic conditions. These plans aim to improve health outcomes with a customized approach to care, including tailored benefits, individualized care plans, and a dedicated care team.