Medicare & Medicaid Special Needs Plans

Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.

Some people have both Medicare and Medicaid. If so, they could be “dual eligible.” That’s where dual special needs plans — or “dual” plans — come in. Dual plans combine the benefits of both Medicare and Medicaid into one simple health plan. If you have Medicare and Medicaid, chances are you could qualify for a dual plan.

Dual plans go beyond either Medicaid or Original Medicare alone. You’ll keep the Medicaid benefits you get today. And better yet, with a dual plan, you could get many extra benefits and features than Original Medicare at no extra cost. 

A Special Needs Plan (SNP) is a type of Medicare Advantage plan that combines all the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D) but is only available to those beneficiaries who have an additional qualifying condition. For example, those who:

• have a specific chronic health condition
• are eligible for both Medicare and Medicaid
• are a resident of a long-term care facility

1. people who live in certain institutions (like a nursing home) or who require nursing care at home, or 
2. people who are eligible for both Medicare and Medicaid, or 
3. people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join an SNP at any time.

You can get your Texas Medicare benefits through Original Medicare, or you can choose a Medicare Advantage Plan. With Original Medicare, the government pays for your Medicare benefits when you get them. Medicare Advantage Plans, the Part C of Medicare are offered by private companies that have been approved by Medicare. Medicare pays these companies to administer your Medicare benefits.

If you join a Texas Medicare Advantage Plan, the plan will provide all your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. They are completely different than a Medicare Supplement Insurance (Medigap) policy.

There are several types of Texas Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans: In most HMOs, you may only go to doctors, other health care providers, or hospitals that are in the plan’s network, except in an emergency or urgent situation. You also need to get a referral from your primary care doctor for diagnostic tests or to see other doctors or specialists.

Preferred Provider Organization (PPO) plans: With a PPO, you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. You generally pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) plans: PFFS plans are like Original Medicare in that you can generally go to any doctor, other health care provider, or hospital if they agree to accept the plan’s payment terms. The plan will determine how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Special Needs Plans (SNPs): SNPs provide specialized and focused health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.

HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.

Medical Savings Account (MSA) plans: These plans combine a high-deductible health plan with a bank savings account. Medicare will deposit money into the account (usually less than the deductible). You can use the money to pay for your health care services throughout the year. MSA plans do not offer any Medicare drug coverage. If you want drug coverage, you must join a Medicare Prescription Drug Plan, Part C of Medicare.

To be eligible to enroll in a Texas Medicare Advantage plan you must have both Medicare Parts A and B and live in the plan’s service area. People with End-Stage Renal Disease (permanent kidney failure) generally cannot enroll in a Medicare Advantage Plan.

You must continue to pay your Part B premium and generally pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join. Some may have a $0 premium.

Texas Medicare Advantage Plans must cover all the services that Original Medicare covers except for hospice care. Original Medicare will cover hospice care even if you are in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you will always be covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.

Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for both the plan’s medical and prescription drug coverage.

Ashford Insurance offers Medicare Advantage Dual Eligible Plans (Part C of Medicare).

Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.

Whether an “all-in-one” Medicare Advantage plan or a standalone Part D plan suits you, Ashford Insurance can help. Get a quote for prescription drug plans online now at no cost to you. Or, let one of our licensed agents review your options and find the best drug insurance plan for your unique needs. Just give us a call today at 817-952-3153.

Ashford Insurance also offers Medicare Part D Prescription Drug and Medigap Plans.