I have a chronic condition: Is there a special plan for me?
If you have been living with a chronic condition and reached Medicare eligibility, you are able to sign up for a healthcare plan that is specifically geared toward your treatment. There are millions of seniors around the country who have chronic conditions that need specialized care to treat certain diseases. As a result, Medicare offers Special Needs Plans. These plans offer coverage that is specifically designed to treat seniors with specialists and prescription drugs that are generally used for chronic diseases.
Special Needs Plans
SNPs are a type of Medicare Advantage Plan that cover hospital stays, doctor visits and services, and come with its own prescription drug plan. These plans are special because they are tailored to a person's specific needs. This means the benefits you receive will vary depending on your condition.
Doctors who specialize in certain diseases may be covered under these plans while they might not be part of the Original Medicare network. However, Medicare recipients will need a referral from their primary doctor to see a specialist and for Medicare to cover the expenses. There may also be extra benefits for those with SNPs, such as additional days in the hospital that will be covered by Medicare. These fringe benefits will depend on the specific plan chosen and the needs of a person's condition.
Some of these plans may also come with a Medicare care coordinator, or a person who aids patients to get the help and care that they need. These duties can include helping a Medicare recipient follow their doctor's orders and remember to schedule preventive services like cancer screenings. A care coordinator might help a person stay on a schedule with their prescription medications or stay on track with senior nutrition and fitness. This person may also be useful for coordinating between Medicare and Medicaid benefits for a person who is eligible for both.
Who can join?
There are limitations on who can sign up for an SNP. You must have a chronic disease or condition that is cleared by Medicare. You are also eligible for one of these plans if you qualify for both Medicare and Medicaid (Dual Eligible SNP) or if you live in an institution such as a nursing home or require at-home nursing (Institutional SNP).
Qualified chronic disease and conditions are limited by Medicare, but may include diabetes, chronic heart failure, dementia, some neurological disorders, HIV/AIDS or End-Stage Renal Disease. Other conditions may also apply but are subject to Medicare eligibility requirements. Membership is also limited by group, so a person with chronic heart condition will have a plan designed for their specific needs only. Other Medicare beneficiaries with the same condition would sign up for the same SNP with benefits that feature a network of specialists for treatment of the disease. In addition to doctor visits and services, the prescription drug coverage in the plan would include drugs that are typically used to treat the condition.
What is the cost?
If you are eligible for Medicare only – not both Medicare and Medicaid – and you sign up for an SNP, your expenses will be similar to other Medicare Advantage Plans. The exact costs will depend on the plan you choose.
If you are qualified for both Medicare and Medicaid, most of the costs of your health care plan are covered, with few out-of-pocket expenses.
When can I join?
You can sign up for a Medicare SNP at any time once you are eligible if you are dually qualified for Medicare and Medicaid. For those who are newly eligible for Medicare and not Medicaid, you can sign up during a seven-month initial enrollment period that begins three months before you turn 65, the month of your birthday and the following three months after you turn 65. After signing up during the initial enrollment period, coverage begins July 1. If you are already enrolled in Medicare, you can sign up for any SNP during the open enrollment period, which runs Oct. 15 through Dec. 7 annually. Coverage begins on Jan. 1 for those who sign up during general open enrollment.
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