Medicare SNPS, Who Can Join, Benefits, and Cost

Medicare SNP Plans

Medicare Special Needs Plans (SNPs) are specially coordinated plans for certain qualified individuals (limited to patients with chronic or disabling conditions and who have limited incomes). It’s a unique Medicare Advantage Plan, where the federal government pays approved private companies (meet MOC requirements) to cover special health care or financial needs.

Like all Medicare Advantage Plans (HMO, PPO, etc.), SNPs must provide the same benefits, rights, and protections as Original Medicare(although with different rules, restrictions, and costs).

How Medicare SNPs work

SNPs will only offer specialized coverage and medical care for those who meet strict eligibility requirements. This is mostly for individuals who can’t get coverage through Medicare Part A and B due to chronic or disabling conditions.

Members are only to receive care within SNPs care networks (except for emergencies) and patients need referrals to see specialists. Some SNPs may offer additional benefits like vision and hearing care.

With Medicare SNP:

• Members are still in the Medicare Program.
• Patients are able to access full Medicare rights and protections.
• Plan Offers complete Medicare Part A and Part B coverage (beneficiaries generally pay premiums for Part B-in some cases plan may cater all or some part of the premium. They may also pay a Medicare SNP premium to help cover the costs of providing Part A and Part B benefits, prescription drug coverage, and any other plan extras being offered).
• Plan Provides access to Medicare prescription drug coverage.
• The plan may offer extra benefits tailored to the groups it serves, such as diabetes services, care coordination, and/or other health and wellness programs.
• If you have Medicare and Medicaid or have limited income and resources, some or all of your plan’s out-of-pocket costs may be covered.
• Beneficiaries have the option of switching to another Medicare plan or returning to their Original Medicare.

Who can join a Medicare SNP

Eligibility

It’s based on an individual fitting into one of the following groups (or a subset of these groups):

1. Institutional Special Needs Plans (I-SNPs):

People who live or are expected to live for at least 90 days or longer in a long-term skilled care facility (nursing facility, intermediate care facility, or inpatient care facility) or who require nursing care at home

2. Dual Eligible SNP (D-SNP):

People who are eligible for both Medicare (due to age or disability) and full Medicaid (due to low income). The plan combines your Medicare Part A and Part B benefits, and your Medicare Part D prescription drug coverage. You also get extra benefits not provided by either Medicare or Medicaid.

3. Chronic Condition SNP (C-SNP):

These are People with specific chronic or disabling conditions (like Auto Immune disease, End-Stage Renal Disease (ESRD), Neurologic disorders, chronic heart failure, or Cancer). This should be as per the categories defined by CMS.

Plans can further limit membership beyond these groups.

You also need to live within the plans service area as you are required to receive care within SNP care networks.

Enrollment

If eligible, enrollment can be during the regular Medicare Advantage enrollment period. Individuals can also enroll during a Special Enrollment Period (SEP).

Benefits and services covered in Medicare SNP

What Services Do Medicare SNPs Cover

Medicare SNPs must use Medicare’s coverage rules to decide which services are medically necessary and covered. This means that if a service is considered medically necessary under Original Medicare, the Medicare SNP must cover the service.

This includes;

• SNPs must cover all medically-necessary and preventive services covered under Medicare Part A and Part B, and
• Prescription drug coverage under Part D. Medicare SNP formularies may be designed to cover the drugs most needed to treat the special needs of its members.

Some Medicare SNPs may offer nonmedical benefits (like pest control and food security) that address the social determinants of health.

Where is Medicare SNP offered

This strictly depends on where your carrier is operating.

There is a huge possibility of your Medicare SNPs may not be available in all parts of the country, or may offer only certain plans in more than one area, and with different benefits and costs.

Most plans allow their members to change plans at least once during each of the first three quarters of the year.

Cost of Medicare SNP

The cost of joining Medicare is usually financed by a combination of Medicare/Medicaid funding and premiums paid by patients.

For patients financed with Medicare

The SNP cannot charge higher than the cost-sharing amounts than to be paid under Original Medicare or Medicaid.

For patients not financed with Medicare

The exact cost will depend on the plan you choose. In general, this will be:

• Monthly Medicare Part B premium.
• Additional monthly premium above the Medicare Part B premium (for Medicare Part A and Part B services), prescription drug benefits, and extra benefits.
• Any plan deductible, coinsurance, or copayment amounts.

Care coordinator in Medicare SNP

Most Medicare SNPs may require their members to have a Primary Care Physician(PCP) or a care coordinator to help with accessing the best care and information.

Bottom Line

SNPs are designed to offer Specialized care. Technically, they are Medicare Advantage plans tailored for special medical concerns) with enrollment eligibility requirements.

SNPs typically include the same benefits as a Medicare Part D prescription drug plan.

Before enrolling, make your Advance Coverage Decisions. Ensure the plan will cover the needed services (and whether they are considered medically necessary).

Also, understand their Appeal process on any service you think should be covered or provided.

In a nutshell, determine;

• It covers the services you need
• If the needed plan is available in your area(where you live)
• Providers or vendors in the panel(contracted )
• The monthly premiums
• The total out-of-pocket costs, and any caps on this.