Navigating Special Needs Health Plans: A Comprehensive Guide

Back in 2003, the government spotted a group of beneficiaries who needed more coverage than was available at that time. Special Needs Plans, or SNPs, were born. Built for those with certain debilitating diseases, health care needs requiring additional personal support, or Medicaid, SNPs are meant to provide additional support for these conditions. Let’s get into the details of SNPs and see if one of the three types is right for you.

Tailored coverage

If you think you might want a SNP, you’re in luck—carriers have put more focus on these plans than ever before. While functionally similar to a Medicare Advantage plan, Special Needs Plans often go beyond the benefits you’ll find with Medicare Advantage. But we will go into more detail about that later.

These plans are managed by carriers but overseen by the government, just like Medicare Advantage plans, so each plan can have different rules regarding what is and isn’t covered, just like a Medicare Advantage plan. SNPs can have HMO or PPO networks.

3 ways to play

There are three types of SNP plans out there. But before we decide what type of SNPs to look into, we have a few boxes to check first. Beneficiaries must be enrolled in Parts A and B to begin their SNP journey. Once that is squared away, they must live in an area offering these plan types. In Michigan, everyone should have access in one way or another to a D-SNP plan, but only those in certain areas will have access to C or I SNPs. Next, you must meet the requirements set by that plan, which can be identified by the first letter of the SNP: D, C, or I.

First, is the most common: Dual eligible, or D-SNP plans. If you have all the aforementioned things taken care of and also qualify for Medicaid, then you can get a D-SNP plan. Simply give your agent your Medicaid number, social security number, and Medicare number to apply for one of these plans.

Next most common is the C-SNP, or Chronic condition plans. There are 15 approved conditions you can live with to qualify for a C-SNP plan. Depending on the plan, you might have one or a combination of these 15 diseases. A doctor will have to verify that you have the disease in order to get approval after applying, so make sure your doctor is on deck to advocate for you, or have a note from a doctor ready when you apply.

Finally, if you reside in a care facility, like a nursing home or a swing bed hospital, you can qualify for an I-SNP, or institutional plan. To qualify for a plan like this, you must live in some sort of supportive care for 90 days. Or, you can have a physician sign off confirming a need for that level of care in the next 90 days.

Collaboration is key

The largest benefit you can look forward to with a SNP is the coordination of care required by SNPs. To remain compliant, each SNP must submit a Model of Care proving it does something additional to benefit its members. Additional communication between providers is required in a SNP as well. This streamlined approach to communication among healthcare professionals ensures a holistic and integrated approach to care.

What does a SNP cover?

These plans are required to cover everything traditional Medicare covers at the same price, plus whatever is outlined in that Model of Care we talked about earlier. But, it doesn’t stop there.

SNPs can cover a range of therapies, including physical therapy, occupational therapy, speech therapy, and behavioral interventions.

The cost of necessary assistive devices and equipment, such as wheelchairs, communication devices, and adaptive technology might also be covered.

Part D is rolled into SNPs, so there is no need to worry about additional prescription drug coverage when you choose a SNP. If you have any Extra Help, you can apply that to your drug costs within the SNP, just like you would if you had a prescription drug plan. Dental, vision, and hearing benefits can be added on separately.

Just remember, all of these benefits are going to depend on what is outlined in that model of care. So think of SNPs as regular Medicare Advantage Plans, with a prescription drug plan, and extra perks sprinkled in.

No need for prior authorizations

Prior authorizations also function differently than in standard plans. In a standard plan, if a drug or treatment requires prior authorization, the provider must ask for approval from the plan before the treatment or procedure can happen. If approval is not granted, it will not be covered, and you will be responsible for paying for that procedure. Prior authorizations have the potential to make treatment more complicated: permissions might not carry over if anything like plans, networks, or providers change between the recommendation is given and the treatment occurs.

But with SNP plans, once you get prior authorization, it cannot be revoked for any reason until you get that care, regardless of any changes to your plan, provider, or diagnosis.

What are the costs?

Payment also is a bit different for SNPs. You will still be responsible for your traditional Medicare premiums (Parts A and B). But, if you qualify for any Cost Savings Programs, like the Qualified Medicare Beneficiary program (QMB), Specified Low Income Medicare Beneficiary Program (SLMB), or Qualified Individual Program (QI), you will probably only have to pay for part of your premium, if any at all, depending on which program you qualify for. Check with your health insurance agent when enrolling to make sure your plan works with that Cost Savings Program.

When can I get one?

Well, for the most part, you can snag a SNP whenever you can get a Medicare Advantage plan: when you first turn 65; when you experience a qualifying life event; if your qualification status changes, such as newly qualify for Medicaid or Extra Help; or during the Annual Enrollment Period from October 15 to December 7. You can also switch between SNPs once a quarter from January 1 to September 30. This is true for all Medicare Advantage plans. For more details on all the times you can switch, check out our insight on switching Medicare plans.

But it’s worth mentioning again that if a C-SNP is available to you, you can use the condition as your ticket to ride without having to fall within any enrollment period at all. Just have your doctor vouch for you either through a doctor’s note when you apply or verbally to the carrier if you provide them as your PCP. Just make sure that your doctor does at some point verify you have that condition—you will not keep your coverage if you aren’t verified. You’ll get a new Special Enrollment Period to enroll in something else.

Interested in making a switch?

Special needs health plans are instrumental in providing comprehensive and tailored healthcare solutions for those with needs beyond the norm. If you are interested in making a change to a Special Needs Plan, contact an Action Benefits agent, and try to have a doctor’s note or your Medicaid number ready if you can!