Special Needs Programs were created as part of the Medicare Modernization Act (also known as “MMA”) of 2003. Special Needs Plans (also known as “SNPs”) are Medicare Advantage plans designed to attract and enroll Medicare beneficiaries who fall into a certain special needs demographic. There are two types of Medicare Advantage Special Needs Plans. First, is the exclusive Special Need Plan which enrolls only those beneficiaries who fall into the special needs demographic. The other type is the disproportionate share Special Needs Plan. The disproportionate share Special Needs Plans enroll a greater percentage of the target special needs population as compared to a national percentage of the target population.

More specifically, these Medicare Advantage plans, or Special Needs Plans, focus and limit enrollment and services to the following Medicare beneficiaries:

1) Individuals who live in certain institutions (like a nursing home) or who require nursing care at home;

2) Individuals who are eligible for both Medicare and some form of Medicaid; or

3) Individuals who have specific chronic or disabling conditions (like diabetes, ESRD, HIV/AIDS, chronic heart failure, or dementia).

While the Medicare Modernization Act allowed changes in enrollment targeting, it did not direct the Center for Medicare and Medicaid Services (also known as “CMS”) to specify requirements for other “special” things that Medicare Advantage Special Needs Plans might do or provide. Examples of things a Special Need Plan provides include benefits, care management and coordination with Medicaid. You can join a Medicare Advantage Special Needs Plan at any time you meet the eligibility requirements. Therefore, if you join a Medicare Advantage Special Needs Plan then the plan should coordinate the services and providers you need to help you stay healthy and make sure you follow your doctor’s or other health care provider’s orders. If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid. If you live in an institution, make sure that plan providers serve people where you live.

A Special Needs Plan is a Medicare Advantage plan (also known as Medicare Part C); therefore, you generally must get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out of area dialysis). The Medicare Special Needs Plan includes coverage for all your original Medical Part A (hospital), original Medical Part B (medical health care services) and prescription drug coverage through one plan.

Depending on the plan, you may still need to pay your Medicare Part B premium in addition to the Medicare Part C Special Needs Plan premium. You may even pay a separate premium for prescription drug benefits and extra benefits. You are also responsible for typical out-of-pocket costs associated with the plan. Those can include a deductible, coinsurance and copayments. Each plan is different so you should review the specific plan documents to see how much you pay. Pay particular attention to the differences in your cost sharing when you use the plan’s network doctors versus out-of-network doctors, if the plan allows you to go outside the network.


Medicare Pathways, Inc.