Medicare Special Needs Plans

A Medicare Advantage Plan allows patients to receive care through a network of providers that contract with Medicare.

Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage Plan that serve individuals with chronic or disabling conditions. These plans require eligible patients to receive care and services from doctors or hospitals in their Medicare SNP networks.

SNP networks vary in size and the populations they serve. Two types of networks include:

  1. Networks covering a specified area. For example, one network may cover an entire state, while another network covers one county. Often, this means that an area might be served by more than one network.
  2. Networks dealing with a certain health issue, like dementia. Providers who provide services to patients with the specified condition can join the network.

Eligibility

To be eligible for a special needs plan, an individual must fit into one of the following groups:

  1. People who live in certain institutions (like nursing homes) or who require nursing care at home
  2. People who are eligible for both Medicare and Medicaid
  3. People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or dementia)

Plans, however, may further limit membership beyond these groups.

Financing

SNPs offer all health care services through a single plan. Medicare SNPs are usually financed through a combination of Medicare funding and premiums paid by patients.

Benefits and Challenges

Patients who are covered under SNPs enjoy many benefits, and becoming an SNP provider means your LTSS program would be directly involved in providing those benefits in a local, culturally appropriate setting. However, there are also challenges related to SNPs.

Benefits

Challenges

  • May cover patients of facility-based care and home- and community-based care
  • Patients can easily coordinate all parts of the health care services they receive
  • Can provide special programs for certain conditions (e.g., a network dealing with congestive heart failure might provide programs that help people with that specific condition)
  • Patients may not need other forms of health insurance to be fully covered
  • Those with Medicare and Medicaid or with limited income may pay little to none of their own money for services
  • Networks or providers may not be available in all parts of the country
  • Each year, networks can choose to leave Medicare, meaning the people they serve will need to find a new network to cover them

Next Steps

Refer back to the results of your needs assessment. Do many of the people who need care in your community fit into the eligible groups listed above? For example:

  • Do you have a significant number of people in your community with dementia who need care? What about End-Stage Renal Disease or congestive heart failure?
  • Are many community members eligible for both Medicare and Medicaid?

If yes, this may mean that many of those needing care in your community could benefit from the addition of your program to an SNP network, especially if there are not any other SNP providers nearby.

Keep in mind that if your program becomes an SNP provider, you will need to actively educate your community, including the leadership, about what that means and help eligible people sign up for coverage. Learn more about good strategies for educating your community.

Resources

Find out more about Medicare SNPs and whether they are a possibility for your LTSS program:

Page Last Modified:
04/17/2019 09:40 AM