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Medicare Advantage Chronic Special Needs Plans (C-SNP)

Medicare Advantage, also known as Medicare Part C, is an alternative way to get Original Medicare (Part A and Part B). It can be a cost-effective and potential money saving option because it has out-of-pocket limits on costs associated with your covered services. Once you reach the limit, you pay nothing for the rest of the year.

 

Unlike Original Medicare, Medicare Part C is offered by private insurance companies. Federal government rules and regulations, however, regulate these private companies.

Medicare Advantage offers five types of plans. These include:

  • Health Maintenance Organization (HMO) plans

  • Preferred Provider Organization (PPO) plans

  • Private Fee-for-Service (PFFS) plans

  • Special Needs Plans (SNPs)

  • Medicare savings account (MSA) plans

 

In this article, we will be discussing Chronic Special Needs Plans (C-SNPs), a sub-type of Special Needs Plans (SNPs), who its beneficiaries are, how to be eligible, what it covers, and more.

Special Needs Plans (SNP) Plans

Special Needs Plans are a type of Medicare Advantage plan. Special Needs Plans will either have an HMO network or a PPO Network. The HMO plans typically have lower costs for healthcare services but are usually more restrictive about where you can actually go to receive that care. PPO SNP plans will generally allow you more freedom to see healthcare providers that are outside of the plans network. However, you will usually have higher out of pocket costs when seeking care from a provider who is not in the plans network. 

Special Needs Plans are created to help specific individuals in different subsets of the population. Eligible people usually meet specific health criteria, such as having certain chronic and disabling health conditions or qualifying for Medicare and Medicaid. These criteria form the two most common types of SNPs. They are Chronic and Dual Eligible Special Needs Plans (D-SNPs).

Chronic Special Needs Plans (C-SNPs)

Chronic Special Needs Plans (C-SNPs) are Special Needs Plans (SNPs) specially designed for eligible individuals with specific severe or disabling chronic health conditions. Each plan sponsor will have their own specific qualifying health conditions to be eligible to enroll. At the time of enrollment, your physician will be asked to fill out a chronic condition verification form. 

This type of SNP usually has a network including hospitals, pharmacies, physicians, specialists, and other health professionals who specialize in treating chronic diseases or conditions that affect their members. C-SNP plans are not available in all areas. Plan availability varies based on the county that you live in.

Am I Eligible For Medicare Advantage Chronic Special Needs Plan (C-SNP)?

Eligibility for Medicare Advantage is the same as Original Medicare. You must be aged 65 and older or have a qualifying disability if you are under 65. However, you must also have one or more of the CMS-approved chronic conditions to qualify for a Medicare Advantage Chronic Special Needs Plan (C-SNP). You also must have a C-SNP plan available in the county you live in.

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Qualifying Chronic Conditions Under C-SNPs

There are 15 SNP-specific chronic conditions. They include: 

  1. Chronic alcohol and other drug dependence

  2. Autoimmune disorders limited to the following:

  • Polyarteritis nodosa

  • Polymyalgia rheumatica

  • Polymyositis

  • Rheumatoid arthritis

  • Systemic lupus erythematosus

  1. Cancer, excluding pre-cancer conditions or in-situ mass

  2. Cardiovascular disorders limited to:

  • Cardiac arrhythmias

  • Coronary artery disease

  • Peripheral vascular disease

  • Chronic venous thromboembolic disorder

  1. Chronic heart failure

  2. Dementia

  3. Diabetes mellitus

  4. End-stage liver disease

  5. End-stage renal disease (ESRD) requiring dialysis

  6. Severe hematologic disorders limited to:

  • Aplastic anemia

  • Hemophilia

  • Immune thrombocytopenic purpura

  • Myelodysplastic syndrome

  • Sickle-cell disease (excluding sickle-cell trait)

  1. HIV/AIDS

  2. Chronic lung disorders limited to:

  • Asthma

  • Chronic bronchitis

  • Emphysema

  • Pulmonary fibrosis

  • Pulmonary hypertension

  1. Chronic and disabling mental health conditions limited to:

  • Bipolar disorders

  • Major depressive disorders

  • Paranoid disorder

  • Schizophrenia

  • Schizoaffective disorder

  1. Neurologic disorders limited to:

  • Amyotrophic lateral sclerosis (ALS)

  • Epilepsy

  • Extensive paralysis (i.e., hemiplegia, quadriplegia, paraplegia, monoplegia)

  • Huntington’s disease

  • Multiple sclerosis

  • Parkinson’s disease

  • Polyneuropathy

  • Spinal stenosis

  • Stroke-related neurologic deficit

  1. Stroke

The Chronic health conditions that we see most commonly used as qualifiers for specific C-SNP plans are: 

 

  1. Chronic Lung Disorders like COPD

  2. Diabetes Mellitus

  3. Congestive Heart Failure (CHF) and other Cardiovascular Diseases 

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What Do Medicare Advantage Chronic Special Needs Plans (C-SNPs) Cover?

Medicare Advantage Chronic Special Needs Plans (C-SNPs) offer the same coverage as Medicare Part A (Inpatient/hospital services) and Part B (outpatient/medical services). They also may provide supplemental coverage for specific items and services, including:

  • Prescription drug coverage (All SNP plans must cover prescription drugs)

  • Routine Vision care, including glasses and contacts

  • Routine dental care, including x-rays, exams, and dentures

  • Hearing care, including testing and hearing aids

  • Wellness programs and gym memberships

  • Medical Transportation

  • Non-medical services including meal delivery, home air cleaners, and home modifications.

 

To enjoy the highest coverage and benefits from SNPs, you must receive non-emergency care from in-network providers. Some SNPs cover services from providers out of network, while some do not and may affect your costs. All SNPs must provide drug coverage.

When Can I Enroll In A Medicare Advantage Chronic Special Needs Plan (C-SNP)?

You can enroll in a Medicare Advantage Chronic Special Needs Plan (C-SNP) during one of these periods. Keep in mind that you also must have a qualifying chronic condition that meets the eligibility requirements of an available C-SNP plan. 

Initial Enrollment Period

For people new to Medicare for the first time, you can choose a Medicare Advantage C-SNP during the Initial Enrollment Period (IEP). 

The initial enrollment period refers to the 7-month window you have to enroll in Medicare when you turn 65. This 7-month period includes the three months before the month you turn 65, your birth month, and three months after the month you turn 65.

Medicare Open Enrollment Period

The Medicare Open Enrollment Period is also known as the Annual Election Period (AEP) and runs from October 15th through December 7th every year.

If you’re already enrolled in Original Medicare, you can change to a Medicare Advantage C-SNP or switch from one C-SNP to another during the Medicare Open Enrollment Period. All changes you make during this period will go into effect on January 1st of the following year.

Special Enrollment Period

This enrollment period only happens when there is a qualifying situation or event for it. Some of these situations include:

  • Being diagnosed with a severe or disabling condition

  • Moving into, currently living in, or leaving a nursing home

  • Moving outside of your Special Needs Plan’s service area

  • Your Special Needs Plan leaving the Medicare program

 

During the Special Enrollment Period (SEP), you can enroll in a C-SNP, switch from one C-SNP to another, or revert to Original Medicare.

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