Fact Sheets

BENEFICIARIES WITH SPECIAL NEEDS CAN GET HELP FROM MEDICARE MANAGED CARE PLANS

Background:   Medicare beneficiaries who live in certain types of institutions, those who have chronic, severe or disabling medical conditions, and those who have both Medicare and Medicaid coverage can enroll in a Medicare Advantage/prescription drug plan with benefits tailored to meet their unique needs.  These “special needs plans (SNPs)” were created by the Medicare Modernization Act of 2003 to serve beneficiaries with serious, long-term illnesses who may have multiple medical conditions and multiple treatment modalities. Special needs plans offer better coordination of care for these beneficiaries than many currently receive. Special needs plans typically have specialists in the diseases affecting the populations they enroll and clinical case management programs targeted to the needs of this special population. They are also expected to have formularies that include the drugs most needed by these beneficiaries.

Who Can Enroll in a Special Needs Plan?

• Beneficiaries who reside, or who are expected to reside, in a long term care facility for 90 days or longer.  A long-term care facility is defined as either: skilled nursing facility, a nursing facility, an intermediate care facility, or an inpatient psychiatric facility.
• Those living in the community who require a level of care that is equivalent to those living in a long term care facility.
• Anyone who is eligible for both Medicare and Medicaid services
• Beneficiaries with chronic conditions such as diabetes, congestive heart failure, mental illness and HIV/AIDS.  Plans will be expected to include providers who specialize in the conditions of the enrollees.

Some dually-eligible beneficiaries who are currently in Medicare Advantage plans that will now become SNPs will remain in that plan automatically. They may opt-out of that plan any time.

Special Needs Plans Stats

Currently, CMS has approved 275 special needs plans to operate around the country in 2006.  This is a huge increase over the 125 approved for 2005 and an even greater improvement since CMS authorized 11 to operate in 2004.   Of the 275 plans operating in 2006, 226 will enroll beneficiaries who are dually eligible for Medicare and Medicaid. Thirty-six plans will be designed just for residents of long-term care facilities and thirteen will focus on those with chronic conditions.  There will be SNP Regional Preferred Provider Organizations operating in Fl, HI and NY for 2006.

Finding a Special Needs Plan

To find a local SNP that is right for someone with special health needs, visit www.medicare.gov and click on “Compare Medicare Prescription Drug Plans” or by visiting www.medicare.gov/mppf and following the instructions on the home page.

The States and CMS have partnered to ensure that Medicare and Medicaid beneficiaries will have no disruption in the prescription drug benefits they receive come January, 2006.   Many States already have business relationships with Medicare Advantage organizations, which include providing a smooth transition to a plan such as a SNP for individuals eligible for both Medicare and Medicaid.  CMS also encourages anyone with Medicare and Medicaid to call your State Medicaid Agency to find out all of the options available in your area. 

http://www.cms.hhs.gov/healthplans/specialneedsplans/default.asp