How Medicare Chronic Special Needs Plans (SNPs) Work

A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan that offers special benefits for those eligible. Like all Medicare Advantage plans (also called Medicare Part C), SNPs are private insurance plans approved by Medicare.

All Advantage plans provide all the benefits of Medicare Parts A (hospital coverage) and B (medical coverage) and often include extra coverage like dental insurance or wellness programs. Most Advantage plans also cover prescription drugs (Part D).

Medicare SNPs offer all the benefits of an Advantage plan but are customized for specific health care needs. The kinds of special needs plans available to you depend on where you live. For example, Humana provides an SNP for Medicare recipients in Florida who have diabetes.

A Medicare SNP can be a good choice for your health care coverage depending on:

• your income
• the other benefits you're eligible for, and
• the availability of other Medicare Advantage plans in your area (see more on the benefits of SNPs below).

But note that choosing a Medicare Advantage plan is somewhat complicated. You'll want to study all the plans available in your area and consider which is best for you.

Who Qualifies for Medicare Special Needs Plans?

Medicare rules limit who can enroll in an SNP. First, you must be eligible for Medicare Parts A and B to join an SNP. And to qualify for Medicare Parts A and B, you need to be over 65 or have a disability and receive SSDI (Social Security disability insurance) benefits (or have end-stage renal disease).

Second, to be eligible to enroll in an SNP, you must either:

• have a chronic condition
• be eligible for Medicaid (and Medicare), or
• need institutional-level care.

Chronic Condition Special Needs Plans

Medicare allows private insurance companies to offer chronic condition SNPs (C-SNPs) focused on the needs of Medicare beneficiaries with particular chronic and disabling conditions. A C-SNP is generally most appropriate for someone with a serious chronic or debilitating condition who needs specialized care.

Not every chronic medical condition qualifies for C-SNP coverage. In 2024, the conditions that make someone eligible for a chronic condition SNP include the following:

• diabetes mellitus
• chronic alcohol or drug dependence
• cancer
• cardiovascular disorders
• chronic heart failure
• dementia or Alzheimer's disease
• chronic, disabling mental health disorders like bipolar disorder or schizophrenia
• neurologic disorders like epilepsy, MS, Parkinson's, Huntington's disease, or ALS
• HIV/AIDs
• autoimmune disorders like rheumatoid arthritis and lupus
• end-stage liver disease
• end-stage kidney disease (ESRD)
• severe hematologic disorders like aplastic anemia or sickle-cell disease
• stroke and stroke-related neurologic deficit, and
• asthma, emphysema, or several other chronic lung disorders.

Even if you have one of the conditions on this list, you must check to see whether there's an SNP for your condition offered where you live. C-SNPs aren't required to cover all fifteen conditions, and many are limited to only one or just a few conditions on the list.

Dual-Eligible Medicare Special Needs Plans

Seniors who have low incomes are sometimes "dual-eligible," meaning they qualify for Medicare and Medicaid benefits at the same time. People with disabilities who have low incomes often get concurrent benefits as well. Dual-eligible SNPs (D-SNPs) are a type of special needs plan designed to provide health care coverage for these people.

D-SNPs are Medicare Advantage plans designed to coordinate your federally administered Medicare and state-run Medicaid health care benefits. In some situations, Medicaid will pay all the out-of-pocket health care costs for a dual-eligible Medicare beneficiary.

But the private insurance companies that offer D-SNPs can restrict enrollment to specific categories of dual-eligible beneficiaries, so check to see if you might be eligible for a D-SNP in your area. Dual-eligible SNPs are the most common kinds of Medicare special needs plans.

Institutional Medicare Special Needs Plans

Medicare beneficiaries who live in nursing homes or other inpatient facilities, and those who receive institutional-level care in their homes, can qualify for institutional SNPs (I-SNPs). These special needs plans are also privately operated Medicare Advantage plans.

For Medicare beneficiaries to qualify for an I-SNP, they must live in an institution (or expect to) for at least 90 consecutive days or be expected to need institutional-level care for at least 90 days. Institutional-level care includes:

• long-term care
• nursing services (NF)
• skilled nursing services (SNF)
• intermediate care (for individuals with intellectual disabilities)
• inpatient psychiatric care, and
• rehabilitation services.

Residing in another types of long-term health care facility that provides similar care to residents with similar needs can also make you eligible for an I-SNP.

What Are the Benefits of Medicare SNPs?

C-SNPs focused on particular medical conditions offer benefits that might appeal to people with those conditions. For example, a special needs plan for people with diabetes might have plan benefits that include more coverage for diabetic care than might be available from other Medicare Advantage plans available in that location, such as:

• blood glucose monitoring
• foot care
• vision care
• lower costs for the best medications used to treat diabetes, and
• a network of doctors who specialize in diabetes treatment.

Likewise, a Medicare SNP for dementia patients might offer extra benefits for institutional and home-based care. That could include better coverage for therapies and treatments than other Medicare Advantage plans.

An SNP for dual-eligible individuals might offer the services of a care coordinator. A D-SNP care coordinator helps beneficiaries find the care they need in their communities and will screen its members for housing, food, and transportation needs.

A Medicare special needs plan can make sense for those who:

• have a permanent disability
• need institutional care, or
• have chronic or multiple conditions such as diabetes or diabetes and cardiovascular problems.

Many people can drop their medi-gap insurance policies when they join a special needs plan because their SNP fills in the gaps not covered by traditional Medicare Parts A and B.

When Should You Join a Medicare Special Needs Plan?

Medicare rules restrict when someone can apply for any Medicare plan, including an SNP. A new Medicare beneficiary can join an SNP anytime during the initial Medicare enrollment period.

If you're eligible for Medicare because of your age, the 7-month initial enrollment period begins 3 months before the month you turn 65 and ends 3 months after your birth month. So, if you turn 65 on May 8, 2025, your initial enrollment period would be February 1, 2025, through August 31, 2025. (Find your initial enrollment period using the enrollment tool at ssa.gov.)

If you're still covered under a group health plan through your job or your spouse's job, you can delay enrolling in Medicare—as long as you (or your spouse) are still working and covered by that group insurance. But you'll have a limited enrollment period once the job or health plan coverage ends. (Learn more about Medicare enrollment periods for seniors.)

If you're disabled and qualify for SSDI benefits, you'll be eligible for Medicare 24 months after becoming entitled to disability benefits. So, your initial enrollment period is a seven-month period beginning around your 25th month of disability.

Once enrolled in an SNP plan, you can switch plans only during the open enrollment period (October 15 through December 7) each year. There are a few exceptions to that rule. You can also switch to an SNP, regardless of whether it's the open enrollment period, in either of the following situations:

• You were diagnosed with an SNP-eligible condition.
• You moved out of your current SNP's service area.

How Do You Find a Medicare SNP Where You Live?

You can see which Medicare Advantage plans, including SNPs, are available in your area using the online Medicare Plan Finder at medicare.gov. But many Medicare plans are available, and choosing the best one for you can be confusing.

Fortunately, every state has a State Health Insurance Assistance Program (SHIP) that can provide individualized counseling about the different Medicare Advantage plans available in your area. Your SHIP office can help you determine:

• which SNPs are available where you live, and
• how much you could expect to pay under a particular plan, based on your expected health needs and medications.

In most states, SHIP is part of the agency serving seniors and disabled people. To find your SHIP, use the locator tool at shiphelp.org. You can also learn which Medicare Special Needs Plans are available to you and get the contact information for your local SHIP by calling Medicare at 800-MEDICARE or looking in the back of the "Medicare & You" handbook you should receive each fall.