Medicare Advantage Plans: Special Needs Plans (SNPs) - dummies

Medicare Advantage Plans: Special Needs Plans (SNPs)

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Medicare Special Needs Plans (SNPs) are relatively new additions to the Medicare Advantage program and aren’t available in all areas. They’re similar in structure to HMOs and PPOs, but each individual SNP serves people in only one of the following specific categories:

  • People who live in institutions (such as nursing homes)

  • People who are eligible for both Medicare and Medicaid

  • People who have at least one chronic disabling condition, such as congestive heart failure, mental illness, diabetes, or HIV/AIDS

Here are the main features of SNPs:

  • Eligibility: You must have Parts A and B and live in the service area of your selected plan. To be accepted into a SNP, you must fall into the single category (one of the three just described) that the plan serves. You can’t join a SNP if you have kidney failure (ESRD) unless the plan specifically offers care for this condition. If you develop ESRD after joining a SNP, you can stay in it.

  • Choice of doctors and hospitals: If the SNP works like a HMO, you must go to the doctors and hospitals within the plan’s provider network, except in emergencies or for urgently needed care, and you need a primary care doctor to refer you to a specialist.

    If the SNP works like a PPO, you can go out of network for a higher co-pay and don’t need a referral for a specialist. The plan may assign a care manager to help coordinate your health care needs and other services in the community.

  • Extra benefits: SNPs come with a built-in extra benefit in that they focus on your special circumstances or health condition and coordinate the services you need accordingly. Some plans offer vision, hearing, and/or dental services (though the extent of that coverage greatly varies among plans) and extras such as fitness classes or gym memberships.

  • Prescription drugs: All SNPs must offer Part D drug coverage.

For more information, see the official publication “Your Guide to Medicare Special Needs Plans (SNPs).”