Medicaid Medicare Your Coverage Options

What’s a Medicare Special Needs Plan?

Written by Diane Archer

Medicare offers commercial health insurance coverage to help people with special needs through Medicare Special Needs Plans. The commercial health plans are a type of Medicare Advantage plan, which are only available in certain areas to certain people. If you qualify, should you join?

Each Special Needs Plan (SNP) contracts with the Centers for Medicare and Medicaid Services to meet the needs of people with particular conditions. If you enroll in a Medicare SNP, you will only be covered for care from doctors and hospitals in its network.

Who can enroll in a Medicare Special Needs Plan? A Medicare Special Needs Plan (SNP) is exclusively for people who have particular disabling conditions that the health plan is designed to address, people with both Medicare and Medicaid, “dual-eligibles,” and nursing home residents or other people who need an institutional level of care.

What are your costs in a Medicare Special Needs Plan? As with all Medicare Advantage plans, your costs will vary depending upon the SNP you join and the care you use. However, if you are enrolled in Medicaid as well as Medicare, you should have no out-of-pocket costs so long as you use network providers. Each SNP sets premiums, copays and deductibles differently. All SNPs must provide Medicare Part D drug coverage, but each may cover a different array of drugs and set different copays. 

What are your additional benefits in a Medicare Special Needs Plan? SNPs should offer care management and care coordination services to help you better manage your conditions. But, each one is different. If you are considering one of these plans, you should make sure you understand what additional benefits will be available to you, your out-of-pocket costs, and any restrictions on your access to care. For example, are you required to get a referral from a primary care doctor in order to see a specialist?

Before enrolling in a Medicare Special Needs Plan, make sure you know the tradeoffs between enrolling in that plan and enrolling in traditional Medicare, which covers your care from most doctors and hospitals anywhere in the U.S. Click here to learn key differences between traditional Medicare and Medicare Advantage plans.

If you are unhappy with your SNP, you have the right to disenroll. However, beginning in January 2019, you can no longer disenroll any month. As a general rule, you must remain in the plan for at least three months. Exception: You may disenroll at any time during the Medicare Advantage Open Enrollment Period, between January and March 31 of each year.

Two recent studies reveal that people enrolled in Medicare Advantage plans, including Special Needs Plans, tend to disenroll at high rates and enroll in traditional Medicare when they develop complex conditions.

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