How Special Needs Plans Can Help Your Medicare Clients - Western Asset Protection
How Special Needs Plans can help your clients

How Special Needs Plans Can Help Your Medicare Clients

Medicare offers a variety of Special Needs Plans (SNPs) to Medicare beneficiaries who meet specific eligibility requirements. These Medicare Advantage plans are geared toward individuals in unique situations, such as those with certain chronic health conditions, qualify for Medicaid, or need institutionalized care.

Since some SNPs are only available in certain ZIP codes, it’s important to know which plans are available in the areas where your clients live, as well as which of your clients might be eligible for them.

Benefits of SNPs

For clients who qualify, there are several reasons why a SNP could be beneficial. Many plans offer lower out-of-pocket costs, such as lower deductibles, copays for certain types of providers and services, and costs for medications that treat specific conditions. Some plans offer extra days for a hospital stay or coverage for a care coordinator. (A care coordinator can play a key role in helping those with chronic health conditions manage the many aspects of their medical care, including doctors’ appointments and prescriptions.)

Types of SNPs

There are three types of SNPs, each of which has its own eligibility requirements and Special Enrollment Periods (SEPs).

Chronic Conditions (C-SNP)

C-SNPs are for Medicare beneficiaries with one or more chronic or disabling health conditions. These include:

  • Chronic alcohol and other dependence
  • Autoimmune disorders
  • Cancer
  • Cardiovascular disorder
  • Chronic heart failure
  • Stroke
  • Diabetes
  • End-stage liver disease
  • End-stage renal disease
  • Severe blood disorders
  • Chronic lung disorders
  • Chronic mental health conditions
  • Neurologic disorders
  • Dementia

CMS provides a detailed list of which specific chronic conditions qualify. The insurance carrier for the SNP will require verification of the health condition from the enrollee’s physician within 30 days of entry to the plan.

According to the National Council on Aging, nearly 95% of older adults have at least one chronic health condition and nearly 80% have two or more. It is likely that many of your clients fall into this group.

Special Enrollment Periods

Individuals with newly diagnosed chronic conditions and worsening conditions can join C-SNPs at any time, provided one is available in their area. Once they join, they can make no further changes using this SEP.

Individuals who no longer have the condition that qualified them for the C-SNP may choose a new MA or Part D plan starting from the time they lose their special needs status up to three months after the SNP grace period ends. The grace period is usually one month, but this varies between plans.

Dual Eligible (D-SNP)

D-SNPs are for Medicare beneficiaries who also qualify for Medicaid. Each state administers its own Medicaid program within the guidelines set by the federal government. AHCCCS determines eligibility in Arizona. D-SNPs coordinate coverage between Medicare and Medicaid, which can improve health outcomes for enrollees by making the healthcare system easier to navigate.

Medicaid provides healthcare coverage to 7.2 million low-income seniors nationwide who are also enrolled in Medicare, meaning there is a large potential market for D-SNPs. Most dual-eligible enrollees will also qualify for assistance through Medicare Savings Programs, Extra Help, and your state’s Pharmacy Assistance Program. You should educate your clients on all the programs available to assist them.

Special Enrollment Periods

Anyone who is eligible for both Medicare and Medicaid can join, switch, or drop an MA or Part D plan one time during each of these periods: January to March, April to June, and July to September. The change takes effect on the first of the following month.

Individuals who lose their Medicaid eligibility will have a one-month grace period to recertify their eligibility. If they no longer qualify, they have three full months from the date they were no longer eligible or the date they were notified (whichever is later) to find a new plan. During this SEP they can join, switch, or drop MA or Part D plans, with the option to return to Original Medicare.

Institutionalized (I-SNP)

I-SNPs are for Medicare beneficiaries who need the level of care provided from an institutionalized setting for at least 90 days. This includes a stay at a nursing home, skilled nursing facility, rehab hospital, long-term care hospital, or psychiatric hospital.

Special Enrollment Periods

This SEP covers individuals moving into or out of an institution. It lasts as long as they live in the institution and for two full months after the month they leave the institution. During this SEP they can join, switch, or drop MA or Part D plans, with the option to return to Original Medicare.

Stay in Touch with Your Clients

It’s important to touch base with your clients on a regular basis to stay aware of any changes to their health or financial circumstances. Many of your clients may not know about their eligibility for an SNP. You play a vital role in ensuring your clients have the best possible healthcare coverage for their individual needs.

The team at Western Asset Protection is committed to your success. Please contact our team for more information about how Special Needs Plans can help your Medicare clients.