Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare.
Approximately 51% of those eligible for Medicare opt for a Medicare Advantage plan. These popular plans are provided by private insurance companies approved by Medicare. By law, Medicare Advantage plans must provide at least the same level of coverage as Medicare Parts A and B.
Not only do these plans cover all services that Original Medicare does, many Medicare Advantage plans also include additional benefits not found in Original Medicare, such as prescription drug coverage, dental, vision, and hearing services.
Of those who are enrolled in Medicare Advantage, approximately 20% are enrolled in Special Needs Plans (SNPs).
What makes SNPs such a popular choice for people over 65?
While regular Medicare Advantage plans may offer some care coordination services, SNPs are designed to provide targeted care and limit enrollment to individuals with specific needs.
Get a Free Medicare Supplement Quote
The Different Types of Special Needs Plans
There are three main types of Special Needs Plans, each catering to different groups of individuals:
- Dual Eligible Special Needs Plans (D-SNPs)
- Target Group: Individuals who are eligible for both Medicare and Medicaid (dual-eligible).
- Benefits: D-SNPs combine Medicare Part A and Part B benefits with Medicare Part D prescription drug coverage. D-SNPs also coordinate benefits between Medicare and Medicaid to ensure that enrollees receive the full range of services available to them. They often provide additional benefits such as dental, vision, hearing, care coordination, personal emergency response systems, telehealth options, and transportation assistance.
- Chronic Condition Special Needs Plans (C-SNPs)
- Target Group: Individuals with severe or disabling chronic conditions.
- Conditions Covered: Conditions such as diabetes, chronic heart failure, cardiovascular disorders, chronic lung disorders, end-stage renal disease, and more are covered under these plans. C-SNPs tailor their benefits, provider choices, and drug formularies to best meet the needs of individuals with these specific conditions.
- Institutional Special Needs Plans (I-SNPs)
- Target Group: Individuals who live in a care facility such as a nursing home or require nursing care at home.
- Eligibility: I-SNPs provide specialized care and services for people who need assisted living for 90 days or longer, either in a facility or at home.
Special Needs Plans are a valuable option for individuals with specific healthcare needs. They provide comprehensive care for those who need special services to help manage their health more effectively.
How SNPs Differ from Other Medicare Advantage Plans
There are a few key differences that set SNPs apart from other Medicare Advantage plans.
SNPs can offer benefits, provider networks, and drug formularies that are customized for the specific population they serve. For example, a Chronic Condition C-SNP for diabetes patients may have more endocrinologists in its network and cover additional diabetes-related services.
SNPs are required to provide more robust care coordination services compared to regular Medicare Advantage plans. This often includes:
- Assigning a care coordinator to help members navigate their care
- Developing individualized care plans
- Conducting health risk assessments
- Providing transitional care across settings
Dual Eligible SNPs (D-SNPs) are required to have contracts with state Medicaid agencies and coordinate Medicaid benefits alongside Medicare benefits. This level of integration is not required for regular Medicare Advantage plans.
SNPs must implement a Model of Care approved by the Centers for Medicare & Medicaid Services (CMS) that details how the plan will provide specialized care to its target population.
Many SNPs utilize interdisciplinary care teams to manage complex needs of their members, which may be less common in regular Medicare Advantage plans. In addition, they often have more frequent touchpoints with members and their caregivers. This ensures care needs are being met, and helps to address any issues that may arise as quickly as possible.
The Disadvantages
While Medicare Advantage plans, including SNPs, offer comprehensive coverage, they also have a few disadvantages:
- High Maximum Out-of-Pocket (MOOP) Costs – Medicare Advantage plans have an annual out-of-pocket limit, but these limits can be high, leading to significant costs if you require extensive medical care.
- Network Restrictions – You are typically required to use a network of doctors and hospitals. Going out of network can result in higher costs or no coverage at all, limiting your choice of healthcare providers.
- Prior Authorization Requirements – Many Medicare Advantage plans require prior authorization for certain services, which can delay or deny necessary care.
- Plan Changes – Medicare Advantage plans can change their benefits, provider networks, and costs annually, which can affect your coverage and out-of-pocket expenses.
If you have questions about which plan is right for you, it’s important to explore all your options with an expert who can help guide you through the process. This will ensure you get the best plan for your unique situation.
Get a Free Medicare Advantage Quote
Next Steps
By understanding the types of SNPs, their benefits, and potential drawbacks, you can make an informed decision about whether a Medicare Advantage Special Needs Plan is right for you.
Keep in mind the availability of SNPs varies by location. Insurance companies decide where they will offer SNPs, so these plans may not be available in all areas.
If you are interested in enrolling in an SNP, here are your next steps:
- Get a Quote – Compare SNPs available in your area and look for the best benefits for the best price.
- Contact a Plan – Reach out to the insurance company offering the SNP for more information and assistance with enrollment.
- Sign Up – You can enroll in an SNP during the Medicare Annual Enrollment Period or during a Special Enrollment Period if you qualify.
- Call a PBM for Help – Contact a Personal Benefits Manager for personalized assistance. They can help determine which Medicare plan is right for you, introduce you to other alternatives such as Medi-Share 65+, and assist you in choosing the best plan for your needs.
For Further Reading: Things Medicare DOESN’T Cover—And How to Protect Yourself | How to Buy an Electric Wheelchair or Scooter on Medicare | Navigating Prescription Drug Savings with Medicare in 2024
Lou Spatafore works for MediGap Advisors. As a PBM, his focus is to help people find the best Medicare plan for his clients. Read my full Bio.