Texas Medicare Advantage Special Needs Plans

Medicare Special Needs Plans (SNP) are coordinated care plans that offer targeted care to special needs individuals.  SNP plans are managed through the Medicare Advantage program but have limited enrollment. To qualify as a special needs individual, you must meet one or more of the following criteria:

1. An institutionalized individual,
2. A dual-eligible (Medicare and Medicaid)(Medicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States) person, or
3. An individual with a severe or disabling chronic condition.

An SNP can be any type of Medicare Advantage plan, including either a local or regional preferred provider organization (PPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan.  However, SNPs are specific to the communities they serve:

1. Chronic Condition SNP (C-SNP)
2. Dual Eligibles SNP (D-SNP)
3. Institutional SNP (I-SNP)

Special Needs Plans tailor their benefits, network, and drug formulary to best meet the needs of individuals with special needs. For this reason, all Medicare Advantage Special Needs Plans will include a Part D drug plan.

How Do I Qualify for a Texas Medicare Special Needs Plan?

About ten percent of all Medicare Advantage enrollees have a Special Needs Plan. Most people qualify to enroll in an SNP based on their financial situation (aka, dual eligibles) and/or a chronic health condition. Others qualify because they live in a nursing home or require skilled nursing care at home.

If you qualify for both Medicare and Medicaid, you can keep your Original Medicare (Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage) benefits and use Medicaid for your secondary coverage, or you can enroll in a Dual-Eligible Special Needs Plan (D-SNP).

The benefit of joining a Medicare D-SNP is that your complete breadth of coverage is coordinated by the plan and most of the costs will be covered for you. In fact, you can expect to pay little to nothing on deductibles (A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share), copays, and coinsurance (Coinsurance is a percentage of the total you are required to pay for a medical service) for Medicare Part A (Medicare Part A is hospital inpatient coverage for people with Original Medicare, whereas Part B is medical coverage for doctor visits, tests, etc) and Part B services covered by the plan.  Many SNPs have a $0 monthly premium because your Medicaid benefits cover the premium for you.

Unfortunately, not all people who qualify can find a suitable SNP. Although the availability of SNPs is growing, plans are in short supply in rural areas.

To join a Medicare Advantage SNP, you must have both Medicare Part A and Part B. You also must live in the plan’s service area. Then, you may be eligible if at least one of these conditions is true for you:

• You live in a nursing home or need skilled nursing care at home.
• You have one or more severe or disabling chronic conditions.
• You have both Medicare and Medicaid (dual-eligible).

The Centers for Medicare and Medicaid Services (The Centers for Medicare & Medicaid Services (CMS) is the U.S. Federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Programs) (CMS) defines severe or disabling chronic conditions as follows:

1. Chronic alcohol and other dependencies
2. Autoimmune disorders
3. Cancer (excluding pre-cancer conditions)
4. Cardiovascular disorders
5. Chronic heart failure
6. Dementia
7. Diabetes mellitus
8. End-stage liver disease
9. End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
10. Severe hematologic disorders
11. HIV/AIDS
12. Chronic lung disorders
13. Chronic and disabling mental health conditions
14. Neurologic disorders
15. Stroke

Before you can join a Chronic Illness SNP, your doctor must complete a chronic condition verification form at the time of your enrollment. Your insurance agent will provide you with the form and your doctor can complete and return it to verify your eligibility. For more information about qualifying chronic conditions, visit Medicare.gov.

Institutional Medicare SNPs (I-SNP) are similar to chronic illness plans, but they focus on providing coordinated care for people no longer able to live independently. To qualify, it is expected that the beneficiary will live in the institution, or need at-home skilled nursing care, for at least 90 days.

What are the Benefits of a Medicare Special Needs Plan?

The goal of the Medicare SNP initiative is to coordinate care. For this reason, these special plans combine hospital, medical, and prescription drugs, and other benefits. Doing so makes it easier to coordinate care, makes it easier to follow the advice of your doctor and specialists, for things like diet and prescriptions, and can help you get assistance from the community. This happens because the entirety of your medical care is provided through a single plan.

Each Medicare SNP is designed for the community they serve. An SNP tailors its benefits, doctors, drug coverage, and coordinators to meet specific needs. For instance, if you have diabetes mellitus, you’ll need an SNP that offers special programs to manage care for people with insulin deficiency. It also might help you find the right specialist to treat your condition.

You also may have a care coordinator. This is most common if your SNP is for a chronic condition or because you are in an institution or receive home care. Your coordinator makes sure you get the care you need to get healthy and remain as healthy as possible. They also help you connect with various community services. If you are dual-eligible, a care coordinator may help you coordinate the benefits to help remove the complexity.

You won’t need additional drug coverage. All Medicare SNPs include Medicare Part D (Medicare Part D is Medicare’s prescription drug plan program. Plans are offered by private insurance companies and cover outpatient prescriptions) drug coverage. That means you do not need a separate prescription drug plan, but you do need to verify that the SNP you choose covers your medications. This is particularly true if you have one or more chronic conditions.

How Do I Join a Medicare Special Needs Plan?

The first step is to call Ashford Insurance to set up an in-person or over-the-phone appointment.

When Can I Join a Medicare Special Needs Plan?

If you are joining Medicare for the first time, you can sign up during your first Medicare enrollment period. That is usually the month you turn 65 and the 3 months before and after that month.

If you already have Medicare, you can join during the next open enrollment (In health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions) period. Medicare’s Annual Election Period (AEP) starts on 15 October and ends on 7 December.

Outside of these periods, you may be able to join a Special Needs Plan with a Special Election Period in certain situations. Some situations that may qualify you for a Special Election Period to enroll in a Special Needs Plan or make coverage changes include:

• You are diagnosed with a severe or disabling condition: You can enroll in a Chronic-Condition Special Needs Plan (C-SNP) for beneficiaries with your illness at any time.
• You move into a nursing home or require skilled nursing care at home: You can enroll in an Institution Special Needs Plan (I-SNP) or switch plans at any time.
• You qualify for Medicaid: If you have Medicaid or are newly eligible for Medicaid, you can enroll in a Dual-Eligible Medicare Special Needs Plan (D-SNP) at any time.
• You move outside of your existing Special Needs Plan’s service area: You’ll qualify for a Special Election Period to switch to a new plan.
• Your Special Needs Plan leaves the Medicare program: You’ll qualify for a Special Election Period to switch plans.

It’s important to understand that you can only remain in an SNP for as long as you meet the eligibility criteria of that plan. If your situation changes and you no longer meet the requirements you’ll get a Special Election Period to switch to a different Medicare Advantage plan (Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare Part A and Medicare Part B) or switch back to Original Medicare.

How Much Do Medicare Special Needs Plans Cost?

Depending on the plan, you will typically have the following costs:

• Medicare Part B (Medicare Part B is medical coverage for people with Original Medicare. It covers doctor visits, specialists, lab tests and diagnostics, and durable medical equipment. Part A is for hospital inpatient care) premium
• The monthly premium for your Special Needs Plan
• The extra monthly premium for prescription drug coverage (if the SNP requires it)
• The extra monthly premium for additional benefits (if the SNP requires it)
• Cost-sharing expenses, such as copayments (A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service, coinsurance, or deductibles

If you are dual-eligible, your Special Needs Plan can’t have higher cost-sharing requirements than you’d normally pay in Medicaid or Original Medicare. Also, Medicaid may be able to cover some or all of your premiums (A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums) and/or out-of-pocket costs (Out-of-pocket costs (aka, out-of-pocket medical expenses) are costs that a beneficiary must pay because their health insurance does not cover them. Out-of-pocket costs are found in the deductibles, copayments, and coinsurance outlined in each health).

Depending on your income levels, you may qualify for a Medicare Savings Program (MSP) or Qualified Medicare Beneficiary (QMB) program, which can help pay for costs like premiums, copayments, coinsurance, or deductibles. Contact your state’s Medicaid office for more information, or call 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week.

It’s important to keep in mind that costs will vary, depending on your qualifications for the various financial assistance programs. Medicaid is a state-run program and each state offers different benefits. Plus, our out-of-pocket costs will depend on the healthcare services you need and how often you use them. Each Special Needs Plan is different so you should review the Summary of Benefits document for the plan you’re considering. Make sure you pay careful attention to cost-sharing both in-network and out-of-network, as the cost differential can be significant.

What Questions to Ask?

Before joining a Special Needs Plan, consider getting the answers to these important questions:

• If dual-eligible, does the plan coordinate my Medicare and Medicaid benefits to make them easily accessible?
• If in a nursing home, does the plan’s network include my nursing home?
• What costs should I expect for my coverage (premiums, deductibles, copayments)?
• Is there an annual limit on my out-of-pocket expenses?
• Will I be able to use my doctors? Are they in the plan’s network?
• Are the plan’s in-network providers and facilities in convenient locations?
• Does the plan provide coverage for services I receive from out-of-network providers?
• Do I need a referral to see a specialist?
• Are my medications on the plan’s formulary?
• What special accommodations does the plan make for persons with disabilities?
• What special language and cultural accommodations does the plan make?

Each SNP has its own network of providers. In most cases, you will have to choose a primary care doctor. And in most cases, you will be required to use doctors, hospitals, and other providers in the network. Emergencies are an exception to this rule.

If you aren’t happy with your SNP plan, you may switch back to your Original Medicare benefits at any time. During the annual open enrollment, you can choose another Medicare Advantage or SNP plan.

Ready to find a Special Needs Plan? Call Ashford Insurance at 817-952-3153 today.