Medicare Advantage Special Needs Plans for Chronic Illnesses

These plans are designed to serve the needs of people with specific long-term illnesses, including diabetes, cardiovascular disorders (like coronary artery disease) and chronic heart failure (CHF).

These plans may offer predictable costs for people on Medicare who have conditions that require close medical management and therefore surpass what Original Medicare offers.  Many services are available for a predictable, fixed co-payment, and in many markets there are plans available with no additional monthly health plan premium.  Medical health coverage and prescription drug benefits are bundled into one plan.

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Health Plans for People with Specific Long Term Illnesses

Benefits are designed to encourage preventive care and visits to the doctor so that your conditions are managed and changes are detected early.  All Medicare Part A and B benefits are covered, plus there are additional benefits and services beyond Original Medicare (benefits vary by plan and location).  Depending on your health needs, a care manager may be assigned to help coordinate your care.

Benefits include:

  • No
    additional monthly health premium beyond Medicare Part A and B
  • Built-in
    Part D prescription coverage (some plans with $0 premium)
  • $0
    co-pays for many preventive services such as cardiovascular screenings, immunizations
    and routine physicals
  • Coverage
    for lab tests common to chronic illnesses, such as:

    • Cholesterol
      panels (LCD, HDL, total cholesterol)
    • Urinalysis for creatinine (not a standard urinalysis)
    • 4 electrolyte panels per year
    • Hemoglobin AIC
  • These plans also cover other services Medicare doesn't. Most plans cover:
    • Routine vision exams
    • Routine hearing exams
    • Hearing Aids

Who is Eligible for This Plan?

To enroll in a Chronic Illness Special Needs Plan, you must:

  • Be eligible for a Medicare Advantage Plan (Parts A & B)
  • Have one or more of the specified chronic illnesses:
    • Cardiovascular Disorders:
      • Coronary artery disease (CAD)
      • Cardiac arrhythmia
      • Peripheral vascular disease
      • Chronic venous thromboembolic disorder
    • CHF Chronic Heart Failure
    • Diabetes
  • Have the above condition verified by a physician's office prior to enrollment
  • Reside in the product service area
  • Must not have ESRD (End-Stage Renal Disease)
  • Not have to be on Medicaid

Depending on the area you reside in, the plan may be available as a PPO, HMO, POS, or RPPO.

You must continue to pay Part A and B Medicare premiums like you are currently doing.  In many areas, there is no additional monthly health premium (some plans have a Part D premium).  You are responsible for paying your physician or health care provider for any co-pays or coinsurance not covered by the plan.  There is a limit on out-of-pocket co-pay costs for the year for some plans.

Because of their Medicare and specified chronic illness, individuals can join this Health Plan all year long.  These plans provide a flexibility that other plans do not have.  For quotes and assistance with enrollment, contactMedi Gap Advisors at 800-913-3416 or click here.

Make Sure Your Doctor is On The List

 Before signing up for this Medicare Advantage plan, you want to be sure that there are enough doctors in your area who accept the plan.  The most popular Special Needs plan for people with chronic illnesses is offered by UnitedHealthcare, but feel free to contact us and we'll be happy to see what plans are available that your physician accepts.

Search the drug list

A formulary, or drug list, is a list of prescription medications that are covered under a health plan that offers prescription drug (Part D) coverage.

This list of covered medications can help you and your physician maximize your plan benefits while minimizing your overall prescription drug costs.  A formulary makes it easier for your physician to select a medication that will
be covered by your plan.  This means you will be able to obtain your medicine at your pharmacy of choice more quickly.  You will want to carefully weigh the differences in drug lists against the plan costs and other features when choosing a plan that may best meet your needs.

Generic drugs: The drug formulary covers both brand-name and generic drugs.  A generic drug typically is less expensive and is sold under a generic name for that drug (usually its chemical name).  Because generic drugs are less expensive than their brand-name equivalent, your copayment usually is less, as well.

Coverage limitations: To be covered, drugs must be prescribed for a use that is approved by the FDA or documented in at least one of the specific peer-review compendia identified by the Centers for Medicare and Medicaid Services (CMS).  Prior authorization requires you or your doctor to get approval from the plan before your drug is covered. When you contact us regarding your long-term illness plan, we will be happy to investigate whether there will be any additional coverage limitations on the medicines you take, and we will review prior authorization criteria with you as well.

Coverage determination and exceptions: A coverage determination is a decision made by your plan regarding payment for a drug or the types of drugs covered as part of your benefit.  If you wish to have the plan review its coverage decision based on your individual circumstances, you may request an exception to a coverage determination.

Getting Quotes and Signing

Click here to find out how best to contact us for quotes and assistance with enrollment.