Medicare Special Needs Plans can be a great option for people with certain chronic conditions, people living in nursing homes, or people covered by both Medicare and Medicaid. More information is on our Medicare Special Needs Plans page.
What Services Do Medicare SNPs Cover?
Medicare SNPs must cover all of the medically necessary services and preventive services covered under Medicare Part A and Part B, and prescription drug coverage under Part D. Medicare SNPs may also cover extra services tailored to the special groups they serve, like extra days in the hospital. Contact your plan to learn exactly what benefits and services the plan covers.
Do Medicare SNPs Cover Prescription Drugs?
Yes. All Medicare SNPs must provide Medicare prescription drug coverage. Medicare SNP formularies may be designed to cover the drugs most needed to treat the special needs of its members.
Do You Need to Choose a Primary Care Doctor in a Medicare SNP?
In most cases, Medicare SNPs may require you to have a primary care doctor, or the plan may require you to have a care coordinator to help with your health care.
What Is a Care Coordinator?
Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor’s orders. A care coordinator is someone who helps make sure people get the right care and information. For example, a Medicare SNP for people with diabetes might use a care coordinator to help members monitor their blood sugar, follow their diet, get proper exercise, schedule preventive services such as eye and foot exams, and get the right prescriptions to prevent complications. A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members access community resources and coordinate their different Medicare and Medicaid services.
When You Join a Medicare SNP, Can You Get Health Care from Any Doctor or Hospital?
No. Generally, you must get your care and services from doctors or hospitals in the Medicare SNP’s network (except emergency or urgent care, such as care that you get for a sudden illness or injury that needs medical care right away, or if you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis). Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
Do You Have to See a Primary Care Doctor to Get a Referral to See a Specialist in a Medicare SNP?
In most cases, you will have to get a referral. However, women don’t need a referral to get a yearly mammogram or an in-network pap test and pelvic exam (covered at least every other year).
How Do You Know if the Plan Covers a Service You Need?
Medicare SNPs must use Medicare’s coverage rules to decide which services are medically necessary and covered by Medicare. This means that if a service is considered medically necessary under Original Medicare, the Medicare SNP must cover the service. You can also ask the plan for an advance coverage decision to make sure the service is medically necessary and will be covered. If you ask for an advance coverage decision, you have the right to get a decision from the Medicare SNP.
Do Medicare SNPs Cover Services that Medicare Doesn’t Consider Medically Necessary?
Medicare SNPs generally don’t cover the costs of services that aren’t considered medically necessary under Medicare. If you need a service that the Medicare SNP decides isn’t medically necessary, you may have to pay all the costs of the service. However, you have the right to appeal the plan’s decision.
Extra Help for People with Limited Income and Resources
All Medicare SNPs include Medicare prescription drug coverage (Part D). Usually, you pay a copayment for your prescriptions. If you have limited income and resources, you may be able to get Extra Help paying your prescription drug coverage costs. People who qualify may be able to get their prescriptions filled and pay little or nothing out of pocket. There is no cost or obligation to apply for Extra Help, so anyone who thinks they might qualify should apply. You can apply for Extra Help at any time.
To apply for Extra Help paying for Medicare prescription drug coverage, call Social Security at 1-800-772-1213, or visit www.socialsecurity.gov. TTY users should call 1-800-325-0778. You can also visit your State Medical Assistance (Medicaid) office. After you apply, you will get a letter in the mail letting you know what to do next. If you have Medicare and Medicaid, you qualify for this Extra Help automatically and don’t need to apply.
Can You Keep Your Medigap Policy if You Join a Medicare SNP?
Yes, you can keep your Medigap (Medicare Supplement Insurance) policy if you join a Medicare SNP. However, it may cost you a lot, and you may get little benefit from it while you’re in the Medicare SNP. You may want to keep your Medigap policy until you’re sure you’re happy with the Medicare SNP. If you’re already in a Medicare SNP, or if you’re covered by Medicaid, you don’t need a Medigap policy. Generally, it is illegal for anyone to sell you one in these cases.
If You Drop Your Medigap Policy When You Join a Medicare SNP, What Medigap Protections Do You Have?
If you drop your Medigap policy when you join a Medicare SNP, you may have the right to get another Medigap policy later if either of the following is true:
Your Medicare SNP coverage ends (through no fault of your own).
You join a Medicare SNP for the first time (and haven’t been in another Medicare health plan), and you leave the plan within one year of joining.
If you were new to Medicare when you joined the Medicare SNP, you may be able to choose any Medigap policy you want. If you had a Medigap policy and dropped it when you joined the Medicare SNP, you may be able to get the same Medigap policy back.
What Happens if Your Medicare SNP Coverage Ends?
If your Medicare SNP coverage ends or your plan stops providing care in your area, you can join another Medicare health plan, if one is available, or you can return to Original Medicare. Generally, if you return to Original Medicare, you may also have the right to buy a Medigap policy.
For more information on Special Needs Plans, you can download the CMS Your Guide to Medicare Special Needs Plans PDF, or call MediGap Advisors at 800-913-3416.
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Disclaimer: Medigap Advisors is not connected with or endorsed by the U.S. Government or the federal Medicare program. Medicare has neither reviewed nor endorsed the information contained on this website. This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week.