A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals. A special needs individual could be any one of the following:An institutionalized individual,
A dual eligible, or
An individual with a severe or disabling chronic condition, as specified by CMS.
A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan.
There are three different types of SNPs:
Chronic Condition SNP (C-SNP).
Dual Eligible SNP (D-SNP).
Institutional SNP (I-SNP).
SNPs are expected to follow existing MA program rules, including MA regulations at 42 CFR 422, as modified by guidance, with regard to Medicare-covered services and Prescription Drug Benefit program rules.
All SNPs must provide Part D prescription drug coverage because special needs individuals must have access to prescription drugs to manage and control their special health care needs. SNPs should assume that, if no modification is contained in guidance, existing Part C and D rules apply.
Payment procedures for SNPs mirror the procedures that CMS uses to make payments to non-SNP MA plans. SNPs must prepare and submit bids like other MA plans, and are paid in the same manner as other MA plans based on the plan’s enrollment and risk adjustment payment methodology.
All SNPs must abide by current CMS guidance on cost sharing requirements.
Some Special Needs Plans include care-coordination services to help you better understand your condition and stick to your doctor’s treatment regimen.
Or you might have access to wellness programs to help with a special diet or other lifestyle activities that can help improve your condition. Chronic-Condition Special Needs Plans may include provider networks with physicians and hospitals that specialize in treating the specific condition of its members, or they may have formularies that are tailored to include the prescription drugs that treat that illness.
If you’re enrolled in a Special Needs Plan for dual eligibles, there may be certain social services available to help you coordinate your Medicare and Medicaid benefits.
It’s important to note that you still get all the coverage that is otherwise included with Original Medicare, Part A and Part B, and Medicare Part D.
The Special Needs Plan simply offers extra coverage to help you better manage your particular situation, whether that’s living in a nursing home; coordinating your Medicare and Medicaid benefits; or treating a serious chronic illness.
One key difference between a Special Needs Plan and other types of Medicare Advantage plans is that all Special Needs Plans must cover prescription drugs. In contrast, other Medicare Advantage plans (for example, HMOs and PPOs) may or may not include prescription drug coverage, depending on the specific plan.
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Medicare Advantage Special Needs Plans costs.
Depending on the Special Needs Plan, you will typically have the following costs:.
• Medicare Part B premium.
• Monthly premium for your Special Needs Plan.
• Extra monthly premium for prescription drug coverage (if your SNP requires it).
• Extra monthly premium for additional benefits (if your SNP requires it).
• Cost-sharing expenses, such as copayments, coinsurance, or deductible.