HOW MEDICARE SPECIAL NEEDS PLANS WORK

HOW MEDICARE SPECIAL NEEDS PLANS WORK

HOW MEDICARE SPECIAL NEEDS PLANS WORK DIFFERENTLY FROM OTHER MEDICARE ADVANTAGE PLANS

How Medicare Special Needs Plans Work is a completely different manner of care than regular Medicare Advantage plans. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

 HERE IS MORE INFORMATION ABOUT HOW SPECIAL NEEDS PLANS WORK DIFFERENTLY

DO SPECIAL NEEDS PLANS INCLUDE A NETWORK OF APPROVED PROVIDERS, AND CARE FACILITIES LIKE MOST MEDICARE ADVANTAGE PLANS?

Yes, as a general rule/guideline, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

• Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away.

• If you have End Stage Renal Disease (ESRD) and need out-of-area dialysis

  
  

The reason Special Needs Plans exist is to better serve individuals with a Team approach to their care. Having multiple "Specialists" in their networks is vital to these individuals receiving the best possible care possible. It is also an efficient way to coordinate resources for the Insurance companies. Medicare SNPs typically have specialists in the diseases or conditions that affect their members.

 

ARE PRESCRIPTION DRUGS COVERED UNDER MEDICARE SPECIAL NEEDS PLANS? 

Absolutely, since these individuals typically require more specialized care, ALL of the Special Needs Plans must include Prescription Drug coverage. All SNPs must provide Medicare prescription drug coverage.

 

ARE PRIMARY CARE PROVIDERS MANDATORY? CAN I CHOOSE MY OWN SPECIALIST AS MY PCP? 

For the most part, all Medicare Special Needs Plans do require you to have a primary care doctor. And, some plans require you to have a care coordinator to help with your health care.

 

ARE REFERRALS REQUIRED IN ORDER TO SEE A SPECIALIST WITH SPECIAL NEEDS PLANS?

In most cases, you must receive a referral to see a specialist with Special Needs Plans. Certain services don't require a referral, like these:

• Yearly screening mammograms

• An in-network pap test and pelvic exam (covered at least every other year)

  
  

OTHER IMPORTAN THINGS EVERYONE SHOULD KNOW ABOUT MEDICARE SPECIAL NEEDS AND CHRONIC SPECIAL NEEDS PLANS

INSURANCE COMPANIES MUST LIMIT MEMBERSHIP TO ONLY QUALIFIED INDIVIDUALS

•  People who live in certain institutions (like a nursing home) require nursing care at home, or 

• People who are eligible for both Medicare and Medicaid, or 

• People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.

  
  
  
  

WHAT ARE THE BENEFITS OF HAVING A SPECIAL NEEDS PLAN?

• Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.

• If you have Medicare and Medicaid, your plan should ensure that all of the plan doctors or other health care providers you use accept Medicaid.

• If you live in an institution, make sure that plan providers serve people where you live. 

  
  

A CLOSER LOOK AT HOW THESE MEDICARE ADVANTAGE SPECIAL NEEDS POLANS WORK

HOW CAN YOU JOIN A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN (SNP)

• You have Medicare Part A and Medicare Part B.

• You live in the plan's service area.

• You meet the plan's eligibility requirements, like one of these

CHRONIC CONDITIONS SPECIAL NEEDS PLANS (C-SNP)

TO QUALIFY FOR A C-SNP PLAN, YOU MUST HAVE DOCUMENTATION FROM YOUR DOCTOR VALIDATING YOUR CHRONIC CONDITION. CHRONIC CONDITIONS ARE RECOGNIZED AS BEING DISABLING AND ARE NOT REGARDED AS "TEMPORARY" CONDITIONS.

• Chronic Alcohol and/or other Dependence Disorders

• Autoimmune Disorders

• Cancer (excluding pre-cancer conditions)

• Cardiovascular disorders

• Chronic Heart Failure

• Dementia

• Diabetes Mellifluous

• End-Stage Liver Disease

• Chronic Kidney Disease

• End Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)

• Severe Hematologic Disorders

• HIV/AIDS

• Chronic Lung Disorders

• Chronic and Disabling Mental Health Conditions

• Neurologic Disorders

• Stroke

• COPD

INSTITUTIONAL SPECIAL NEEDS PLANS (I-SNP) 

You live in an institution (like a nursing home), or you require nursing care at home.

DUAL ELIGIBLE SPECIAL NEEDS PLANS D-SNP) 

You have both Medicare and Medicaid.

NOT EVERYONE CAN GET A MEDICARE SPECIAL NEEDS PLAN

Each Medicare SNP limits its membership to people in one of these groups, or a subset of one of these groups.For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure. The plan might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan's drug formulary would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition and have all their care coordinated through the Medicare SNP. 

WHAT IS INCLUDED IN MEDICARE ADVANTAGE SPECIAL NEEDS PLANS THAT MAKE THEM SPECIAL

Medicare SNPs cover the same Medicare services that all Medicare Advantage Plans MUST cover. Most every Special Needs Plan includes the same benefits as other Medicare Advantage plans, things like:

• Health Club Memberships

• Dental Coverage

• Vision Coverage

• Hearing Coverage

• Transportation To Doctors Appointments

• OTC Allowances

Medicare SNPs may also cover extra services tailored to the special groups they serve, like extra days in the hospital. Contact your plan to learn exactly what benefits and services the plan covers.

ARE THERE ADDITIONAL COSTS IF YOU QUALIFY FOR A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN?

If you have Medicare and Medicaid, most of the costs of joining a Medicare SNP will be covered for you. Contact your Medicaid Office for more information and to see if you qualify for Medicaid benefits.If you don't have both Medicare and Medicaid (or get other help from your state paying your Medicare premiums), your exact costs will vary depending on the plan you choose. In general, you will pay the same basic costs of having a regular Medicare Advantage Plan.

WHAT EXACTLY IS A CARE COORDINATOR WITH SPECIAL NEEDS PLANS?

Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. A care coordinator is someone who helps make sure people get the right care and information.For example, a Medicare SNP for people with diabetes might use a care coordinator to help members do these things:

• Monitor their blood sugar

• Follow their diet

• Get proper exercise

• Schedule preventative services (like eye and foot exams)

• Get the right prescriptions to prevent complications

  
  

A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members access community resources and coordinate their different Medicare and Medicaid services.

WHEN CAN YOU LEAVE A MEDICARE ADVANTAGE SPECIAL NEEDS PLAN?

You can stay enrolled in a Medicare SNP only if you continue to meet the special conditions served by the plan.

HERE IS AN EXAMPLE THAT MAY HELP:

Mr. Johnson joined a Medicare SNP that only serves members with both Medicare and Medicaid. Mr. Johnson loses his Medicaid eligibility. Medicare requires Mr. Johnson's plan to disenroll him unless he becomes eligible for Medicaid again within the plan's grace period.

The grace period is at least one month long, but plans can choose to have a longer grace period. If you lose eligibility for the plan, you'll have a Special Enrollment Period to make another choice.

This Special Enrollment Period starts when your Medicare SNP notifies you that you're no longer eligible for the plan. It continues during the plan's grace period, and if you're disenrolled from the plan at the end of the grace period, it continues for 2 months after your coverage ends. It's very important to review your coverage options at this time to make sure you continue to have the Medicare health and prescription drug coverage you want.

FINAL THOUGHT

I serve and have had the honor to serve and service many clients with Special Needs and Chronic Special Needs. I can tell you that the experience of the Medicare Beneficiary and their family members is much higher if tehy are members of a SNP or C-SNP Plan. The quality and access to care is night and day from a normal/regular Medicare Advantage HMO or PPO plan. If you have an older friend or family member, please ask them if they have ever heard od SPN or C-SNP plans.