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Medicare Advantage
Special Needs Plans

Private Fee-for-Service (PFFS) plans are a type of Medicare Advantage plan offered by private insurance companies approved by the federal program. These plans must provide at least the same level of coverage as Medicare Parts A and B, but often include additional benefits. Unlike standardized plans, each carrier has the discretion to determine coverage and costs for their plans.

PFFS plans can have full or partial provider networks, and in some cases, they may not have a network at all. Regardless of the type of network, PFFS plan enrollees can see any provider who accepts Medicare payment and agrees to the plan’s payment terms and conditions.

Medicare Advantage PFFS Plan Benefits

There are three distinct categories of Special Needs Plans that we will briefly outline. If you fall into one of these three categories, a Special Needs Plan could be a suitable choice for your healthcare coverage.

The Three Categories of Special Needs Plans are:

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

Each of these plans requires a primary care physician who will be your primary healthcare provider. This doctor will coordinate all of your care within the Medicare Special Needs plan network in your area.

A Special Needs Plan offers a convenient and all-inclusive option for coverage of the health services you may require, eliminating the need to sign up for various plans. This makes it a more efficient and comprehensive alternative to the original Medicare plan or standard Medicaid services.

Most Special Needs Plans typically fall under a Health Maintenance Organization (HMO) plan.

Medicare Advantage SNP Benefits

The unique coverage provided by Special Needs Plans makes them highly advantageous. These plans are designed to cater to the specific needs of the individuals who qualify for them.

For instance, an SNP that focuses on heart issues may offer a comprehensive network of cardiologists, clinical case management programs, and a personalized drug formulary.

Enrolling in an SNP ensures that individuals receive benefits and coverage that have been tailored to their unique health conditions and treatment requirements. Unlike other Medicare Advantage plans, SNP plans always include prescription drug coverage.

Special Needs Plans offer several other benefits, including routine dental, vision, and hearing coverage, transportation to medical appointments, prescription delivery, installation of medical alert devices, telehealth visits, an allowance for over-the-counter products, routine podiatry care, and incentives for completing preventive services.

Medicare Advantage SNP Limitations

SNP plans, like other Medicare Advantage plans, provide coverage for both Parts A and B of Original Medicare. However, these plans, which are offered by private insurance companies, have their own set of costs, rules, and restrictions. One such restriction is that services can only be received from providers within the plan’s network.

Exceptions to this limitation are made in cases where individuals have a sudden illness that requires immediate care in an emergency room or for those with ESRD who require dialysis outside of the plan’s service area.

Otherwise, SNP policyholders must seek care from an in-network primary care physician or care coordinator, who will assist with setting up treatment and services and provide referrals to specialists if necessary. Specialists must also be within the plan’s network. Annual mammogram screenings, Pap tests, and pelvic exams do not require referrals.

Medicare Advantage SNP Eligibility & Enrollment

To enroll in an SNP, individuals must have already enrolled in Parts A and B of Original Medicare, meet the eligibility requirements for the specific plan, and have the plan available in their area. Those with chronic or disabling medical conditions, sudden illnesses that meet the qualifying criteria, or those living in long-term care institutions may be eligible for an SNP. The Initial Enrollment Period and the Annual Enrollment Period are the two main opportunities to enroll, though those with disabling conditions may be able to enroll in a C-SNP at any time. If an individual becomes ineligible for their SNP plan, they will be given a Special Enrollment Period to choose other coverage.

Medicare Advantage SNP Costs

Dual-eligible individuals who qualify for both Medicare and Medicaid will not have any out-of-pocket costs associated with their D-SNP plan. For other individuals, the cost of an SNP plan will vary depending on which plan they choose. While some plans may have monthly premiums as low as $0, they may require deductibles and copayments for certain services. Each plan sets its own cost-sharing amounts, including deductibles and copayments, for covered services.

Additionally, some Special Needs Plans may offer extra benefits beyond what Original Medicare covers. It’s important to check with the plan directly to understand the coverage rules and any restrictions for these added benefits.

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