The most important thing to know about special needs plans is that they are a type of Medicare Advantage Plan. The specifics of special needs plans as well as eligibility and enrollment differ from other Medicare Advantage plans.


This article is meant to provide information about Medicare Advantage plans and discuss how Special Needs Plans(SNPs) provide the same quality healthcare as other Medicare Advantage plans at a reduced cost to you.


If you have questions about your Medicare benefits or need assistance enrolling, Meadowcrest Family Physicians is here to help.


We are dedicated to improving your health and that dedication extends beyond the office. We believe strongly in Medicare Advantage programs including Special Needs Plans as  we’ve seen the benefits they have offered our patients.

Special Needs Plans(SNPS)

A special needs plan is a type of Medicare Advantage coordinated care plan. Special Needs Plans are designed to offer targeted benefits and limit their enrollment to individuals that meet certain criteria.


These are the three instances in which an individual may qualify for a Medicare Advantage Special Needs Plan.

Individuals with Qualifying Conditions

Certain individuals qualified by  CMS to have a severe or disabling chronic condition are eligible for a Special Needs Plan.


Section 1859(b)(6)(B)(iii) of the Act and 42 CFR 422.2 defines special needs individuals with severe or disabling chronic conditions as those “who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life-threatening; have a high risk of hospitalization or other significant adverse health outcomes; and require specialized delivery systems across domains of care.”


A list of qualifying disabilities and conditions can be found here.

Living in an Institution.

Special Needs Plans cover individuals that require long-term and permanent care at a nursing facility.


The costs of nursing care are very expensive. Standard Medicare Advantage covers the costs when nursing is required in the home. When A Medicare Advantage member moves to a full time facility, They are then eligible for a Special Needs Plan.


Being Dual Eligible

Dual Eligible Special Needs Plans (D-SNPs) are available to those who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (title XIX). Funding for these plans depends on the State of residence and eligibility.



Special Needs Plans Offer More Coverage than a Standard Medicare Advantage Plan.

A Special Needs Plan is any type of Medicare Advantage Care Plan that expands coverage to those with certain conditions. These plans can be part of a local preferred provider organization (LPPO) or part of a regional provider organization (RPPO). Additionally, Health Maintenance Organizations (HMOs) and HMO Point-of-Services offer Special Needs Plans through Medicare Advantage.

There are 3 distinct types of Special Needs Plans (SNPs)

  • Dual Eligible SNP (D-SNP)
  • Institutional SNP (I-SNP)


What Conditions Qualify for a C-SNP?

Not everyone is aware that if they have certain conditions, they are eligible to switch to a Medicare Advantage Plan at any time. They do not have to wait for the Open Enrollment period beginning in the fall. If you have these any of these conditions, you are eligible for a C-SNP:

  • Diabetes
  • Heart Disease
  • Lung Disease
  • Cardiovascular Disease

Special Needs Plan Members May Avoid the Medicare Advantage Donut Hole

The primary benefit of a Special Needs Plan is that members will be unaffected by the Medicare Advantage prescription drug coverage gap. The prescription drug coverage gap also known as the “donut hole” refers to a limit on how much a drug plan will pay for prescription medications.

After $4,660 on covered drugs for the year, Medicare Advantage members enter the “donut hole.”

How Special Needs Plans are Funded by Your Medicare Benefits

Special Needs Plans are expected to follow the Medicare Advantage program rules defined by 42 CFR 422. Additionally, Special Needs Plans are regulated with regard to Medicare-covered services and Prescription Drug Benefit program rules.

For the foreseeable future, SNPs will be subject to existing Medicare Part C and D rules.


Payment procedures for Special Needs Plans (SNPs) are the same as those used by the Center For Medicare Services(CMS) to make payments to standard Medicare Advantage plans.  Medicare Advantage SNP providers are required to prepare and submit bids like standard Medicare Advantage plans. The providers are then paid in the same way as other Medicare Advantage plans. These payments are based on factors such as the plan’s enrollment and risk adjustment payment policy.  Federal regulation requires that all SNPs must abide by current CMS guidance for cost-sharing requirements.

Determining Special Needs Plan Eligibility

Seniors eligible for both Medicare and Medicaid can enroll in a special needs plan. Unlike standard Medicare Advantage plans, an eligible individual can enroll at any time. There are several groups that are eligible for a special needs plan. These groups include individuals living in nursing homes, home nursing care recipients, and those with specific or disabling conditions.

Meadowcrest recommends SNPs and other Medicare Advantage Plans to our patients. If you need assistance enrolling in Medicare Advantage, contact our offices today and we will be glad to help.